Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-01139-267 | Comprehensive Healthcare Inspection Program Review of the Battle Creek VA Medical Center, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures completion of at least 75 percent of all required inpatient utilization management reviews and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that clinical managers initiate and complete Focused Professional Practice Evaluations for the determination of providers’ privileges and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
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| 17-04569-262 | Inpatient Security, Safety, and Patient Care Concerns at the Chillicothe VA Medical Center, Ohio | Hotline Healthcare Inspection | ||
1 The Chillicothe VA Medical Center Director ensures that the windows of patient care areas remain secure in accordance with Veterans Health Administration Center for Engineering and Occupational Safety and Health guidelines.
Closure Date:
2 The Chillicothe VA Medical Center Director makes certain that the Chillicothe VA Medical Center’s policy for Special Observation is followed and monitors for compliance.
Closure Date:
3 The Chillicothe VA Medical Center Director verifies that training and staff competencies are completed for Prevention and Management of Disruptive Behavior and Special Observation as required.
Closure Date:
4 The Chillicothe VA Medical Center Director confers with the Office of Chief Counsel regarding the notification of the patient’s death and discussion of institutional disclosure with the next-of-kin and takes action as appropriate.
Closure Date:
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| 18-00608-247 | Comprehensive Healthcare Inspection Program Review of the Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures that an interdisciplinary facility group reviews utilization management data and monitors compliance.
Closure Date:
2 The Facility Director ensures that the Patient Safety Manager submits an annual patient safety report to Facility leaders at the completion of each fiscal year and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that Executive Committee of the Medical Staff minutes consistently reflect the documents reviewed and the rationale for the stated conclusion in order to recommend approval of clinical privileges for licensed independent practitioners and monitors compliance.
Closure Date:
4 The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations on all newly hired licensed independent practitioners and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data every six months and monitors compliance.
Closure Date:
6 The Associate Director ensures required team member participate in environment of care rounds and monitors compliance.
Closure Date:
7 The Associate Director ensures sterilized surgical instruments in the podiatry clinic are appropriately labeled with expiration dates or statements and monitors compliance.
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8 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
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9 The Facility Director ensures that the Alternate Controlled Substance Coordinator’s position description or functional statement includes an addendum for the Controlled Substance Coordinator’s duties and monitors compliance.
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10 The Facility Director ensures that monthly controlled substance inspections are completed in all required areas and monitors compliance.
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11 The Facility 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:
12 The Facility Director ensures that required pharmacy inspections are completed monthly and monitors compliance.
Closure Date:
13 The Chief of Staff ensures that providers complete suicide risk assessments within the required timeframe for patients with positive Posttraumatic Stress Disorder screens and monitors compliance.
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| 16-04558-249 | VA Policy for Administering Traumatic Brain Injury Examinations | Audit | ||
1 The Under Secretary for Benefits coordinate with the Under Secretary for Health to determine whether veterans who had received initial TBI medical examinations by VHA-contracted examiners and not by one of the four designated specialists, were unintentionally excluded from equitable relief. If additional veterans are identified, the OIG requests that those cases be referred to the VA Secretary for consideration of equitable relief.
Closure Date:
2 The Under Secretary for Benefits confirm whether the names of veterans who were not on the initial list of veterans entitled to equitable relief and later identified by VBA staff and referred for potential equitable relief were submitted to the VA Secretary for consideration. The OIG requests an update of the current status and disposition of those cases.
Closure Date:
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| 16-02103-265 | Review of Accuracy of Reported Pending Disability Claims Backlog Statistics | Review | ||
1 The OIG recommended the Under Secretary for Benefits consider revising which claims are included in VBA’s reported disability claims backlog and provide a clear definition to all stakeholders.
Closure Date:
2 The OIG recommended the Under Secretary for Benefits implement a plan to provide consistent oversight and training of Claims Assistants through national performance and training plans.
Closure Date:
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| 17-02713-231 | Bulk Payments Made under Patient-Centered Community Care/Veterans Choice Program Contracts | Audit | ||
1 The Executive in Charge, Office of the Under Secretary for Health, continue to support processes to prevent duplicate payments made to third-party administrators through the bulk payment process and ensure that proper controls are in place to prevent duplicate payments to third-party administrators through all other current payment methodologies and under future Community Care contracts.
Closure Date:
2 The Executive in Charge, Office of Under Secretary for Health, ensure that Office of Community Care staff and members of VA’s Office of General Counsel continue to work collaboratively with relevant government authorities to review and determine an appropriate process for reimbursement of overpayments by the third-party administrators.
Closure Date:
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| 18-01013-263 | Comprehensive Healthcare Inspection Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas | 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 compliance.
Closure Date:
2 The Associate Director ensures the VA Police regularly test panic alarms at the Hot Springs community based outpatient clinic and monitors compliance.
Closure Date:
3 The Associate Director ensures the VA Police test panic alarms and document response time to alarm testing at the locked mental health unit and monitors compliance.
Closure Date:
4 The Facility Director ensures that the Controlled Substances Coordinator’s monthly summary of findings includes all discrepancies from the inspections and monitors compliance.
Closure Date:
5 The Facility Director ensures that reconciliation of controlled substances dispensing from the pharmacy to every automated dispensing cabinet and returns to pharmacy stock is performed during controlled substances inspections and monitors compliance.
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6 The Facility Director ensures that controlled substances inspectors verify written controlled substance orders during monthly area inspections and monitors compliance.
Closure Date:
7 The Facility Director ensures controlled substances inspectors complete emergency drug cache inspections and monitors compliance.
Closure Date:
8 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 compliance.
Closure Date:
9 The Facility Director ensures that the Joint Leadership Council maintain oversight of all geriatric evaluation program performance improvement activities and monitors compliance.
Closure Date:
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| 17-01770-188 | Intraoperative Radiofrequency Ablation and Other Surgical Service Concerns, Samuel S. Stratton VA Medical Center, Albany, New York | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director ensures that the Facility’s credentialing and privileging program is reviewed for integration of key functions of quality oversight, including the use of quality data for Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation processes and surgical Peer Review program.
Closure Date:
2 The Facility Director ensures that the Facility Peer Review program meets all Veterans Health Administration requirements.
Closure Date:
3 The Facility Director ensures that Surgery Service’s professional practice evaluations include performance data to support provider privileges and contain accurate data.
Closure Date:
4 The Facility Director ensures that a process is developed and implemented to document, report, and track patient cases discussed in the Liver Tumor Board and that meeting minutes are completed and forwarded to oversight groups.
Closure Date:
5 The Facility Director ensures that a process is implemented to track, monitor, and report intraoperative radiofrequency ablation outcomes to Facility and Quality Management leaders.
Closure Date:
6 The Facility Director ensures that the Office of General Counsel is consulted on the three patients with missed or partially missed tumors after intraoperative radiofrequency ablation to determine if institutional disclosure might be appropriate.
Closure Date:
7 The Facility Director ensures that the five additional intraoperative radiofrequency ablation patients the Office of Inspector General referred to the Facility, and any other patients who had intraoperative radiofrequency ablation done by Surgeon A, are reviewed by clinicians with qualifications to assess the outcome of these procedures and actions taken as appropriate.
Closure Date:
8 The Facility Director ensures an external review of intraoperative radiofrequency ablation processes is obtained to identify possible causes of missed tumors and methods to improve practice and outcomes.
Closure Date:
9 The Facility Director ensures that Human Resources and the Office of General Counsel are consulted to determine the appropriate actions, if any, including consideration for ethics review, for staff who were not forthcoming with patients on outcomes of intraoperative radiofrequency ablation.
Closure Date:
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| 17-05244-226 | Accuracy of Effective Dates for Reduced Evaluations Needs Improvement | Audit | ||
1 The Under Secretary for Veterans Benefits Administration implement a plan to ensure staff timely process cases with reduced evaluations, after the decision, to prevent rework and improper payments.
Closure Date:
2 The Under Secretary for Veterans Benefits Administration establish a plan to modify the Veterans Benefits Management System to apply correct effective dates for cases with reduced evaluations for conditions that were no longer service-connected and alert staff when the assigned effective dates are improper.
Closure Date:
3 The Under Secretary for Veterans Benefits Administration remind VA Regional Office staff of the system defect that causes effective dates to be one month later than required for conditions that are no longer being classified as service-connected, until the Veterans Benefits Administration could implement a system change.
Closure Date:
4 The Under Secretary for Veterans Benefits Administration implement a plan to provide refresher training on the proper processing of reduced evaluations to staff who process rating reductions and monitor the effectiveness of that training.
Closure Date:
5 The Under Secretary for Veterans Benefits Administration provide updated guidance to include provisions for when amended proposal letters are necessary.
Closure Date:
6 The Under Secretary for Veterans Benefits Administration implement a plan to conduct periodic reviews for veterans who had evaluations reduced after the first of the month following the final notification letter and before the first of the month following 60 days after the final notification letter, take corrective actions as needed, and provide certification of completion to the Office of Inspector General.
Closure Date:
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| 17-01857-264 | Comprehensive Healthcare Inspection Program Review of the Bay Pines VA Healthcare System, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures that floors in patient care areas are clean and monitors compliance.
Closure Date:
2 The Facility Director ensures that the Alternate Controlled Substances Coordinator’s position description or functional statement includes the Control Substance Coordinator’s duties and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that the Geriatric Evaluation Social Worker performs the required comprehensive psychosocial assessment and monitors compliance.
Closure Date:
4 The Associate Director for Patient Care Services ensures that all staff involved in inserting and managing central lines receive the required central line-associated bloodstream infection prevention training and monitors compliance.
Closure Date:
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15169