Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-03137-208 | Supervision and Care of a Residential Treatment Program Patient at a Veterans Integrated Service Network 10 Medical Facility | Hotline Healthcare Inspection | ||
1 The Facility Director ensures that Facility managers coordinate and implement uniform Program policies and procedures relating to supervision of patients, and that Facility staff consistently follow those policies and procedures.
Closure Date:
2 The Facility Director ensures that the Mental Health Treatment Coordinator and interdisciplinary team develop and document the interdisciplinary treatment plan, as required by Veterans Health Administration and Facility policy.
Closure Date:
3 The Facility Director ensures that the Program offers patient treatment, daily, as required by Veterans Health Administration.
Closure Date:
4 The Facility Director ensures that Program managers regularly evaluate restrictions to patient privileges and methods to reinstate restricted or lost patient privileges, as required by Veterans Health Administration.
Closure Date:
5 The Facility Director ensures that staff document Program patient care in the electronic health record within Veterans Health Administration and Facility requirements and timeframes.
Closure Date:
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| 18-00616-212 | Comprehensive Healthcare Inspection Program Review of the VA San Diego Healthcare System | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that Ongoing Professional Practice Evaluations include service-specific performance data and monitors compliance.
Closure Date:
2 The Associate Director and Assistant Director ensure required team members consistently participate on environment of care rounds and monitor team members’ compliance.
Closure Date:
3 The Assistant Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
4 The Facility Director ensures that controlled substance inspectors perform reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock and monitors compliance.
Closure Date:
5 The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection and infection prevention education and monitors nurses’ compliance.
Closure Date:
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| 17-05432-217 | Delays in Urological Care and Alleged Lack of Non-VA Care Funding at the Beckley VA Medical Center, West Virginia | Hotline Healthcare Inspection | ||
1 The Beckley VA Medical Center Director reviews consult management practices and ensuresconsult timeliness.
Closure Date:
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| 16-05323-200 | Alleged Inappropriate Controlled Substance Prescribing Practices at a Veterans Integrated Service Network 20 Medical Facility | Hotline Healthcare Inspection | ||
1 Veterans Integrated Service Network 20 Director conducts a management review of the care of the patient who is the subject of this report, and confers with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action.
Closure Date:
2 The Facility Director implements a systematic approach to review prescribing of controlled substances to individuals at high-risk for substance abuse or misuse.
Closure Date:
3 The Facility Director strengthens processes that foster interdisciplinary collaboration for the management of patients with complex clinical pain and allows referrals from all Facility staff.
Closure Date:
4 The Facility Director ensures that policy and practice is consistent with Veterans Health Administration Directive 1005, Informed Consent for Long-term Opioid Therapy for Pain.
5 The Facility Director ensures provider accountability for compliance with Veterans Health Administration and Facility controlled substance policies, including opioid informed consent policies.
Closure Date:
6 The Facility Director strengthens the Facility Board that is responsible for controlled substances safety, including clarification of roles, responsibilities, and authority; and the development of clearly written definitions and entry criteria for Category II patient record flags in accordance with Veterans Health Administration policy.
Closure Date:
7 The Facility Director maintains full compliance with the Veterans Health Administration’s peer review directive, including but not limited to the selection of impartial reviewers and removing the service chief level review from the Facility peer review process.
8 The Facility Director performs a focused professional practice evaluation on primary care provider 1’s opioid prescribing practices in high-risk patients.
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| 16-00284-214 | Alleged Inappropriate Anesthesia Practices at the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania | Hotline Healthcare Inspection | ||
1 The James E. Van Zandt VA Medical Center Director ensures that the James E. Van Zandt VA Medical Center’s anesthesia needs and services are evaluated and align with Veterans Health Administration and James E. Van Zandt VA Medical Center policies.
Closure Date:
2 The James E. Van Zandt VA Medical Center Director ensures that service chief provider oversight includes facility-specific privileges and provider-specific Ongoing Professional Practice Evaluations.
Closure Date:
3 The James E. Van Zandt VA Medical Center Director ensures that James E. Van Zandt VA Medical Center leaders consult with the Office of Chief Counsel to determine if the anesthesiologist should be reported to the National Practitioner Data Bank and the State Licensing Board for administrating medications inconsistent with the Food and Drug Administration approved manufacturer’s instructions.
Closure Date:
4 The James E. Van Zandt VA Medical Center Director ensures that the Patient Advocate enters all patient complaints into the Patient Advocate Tracking Systems database; documents issue descriptions and actions taken; and tracks all complaints to resolution.
Closure Date:
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| 17-04354-187 | Patient Overdose Death in a Residential Rehabilitation Treatment Program at a VISN 1 Medical Facility | Hotline Healthcare Inspection | ||
1 The VISN 1 Medical Facility Director ensures that staff receive education about the process for initiating Medication Assisted Therapy for patients enrolled in the Program.
Closure Date:
2 The VISN 1 Medical Facility Director ensures that a standard operating procedure is issued to effectively track patients enrolled in the Program who fail to show for appointments at off-site substance abuse day programs.
Closure Date:
3 The VISN 1 Medical Facility Director ensures that all appropriate staff receive training regarding the standard operating procedure for tracking patients enrolled in the Program who fail to show for appointments in at off-site substance abuse day programs.
Closure Date:
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| 16-02247-165 | VA Southern Nevada Healthcare System's Alleged Unnecessary Use of Outside Vendors to Purchase Prosthetics | Audit | ||
1 The Acting Veterans Integrated Service Network 21 Director ensures the Director of the VA Southern Nevada Healthcare System develops and implements effective processes such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetics Laboratory operates in a manner that maximizes its personnel and on hand inventory to provide veterans with timely and cost effective fitting services for compression garments and orthotic shoes.
2 The Acting Veterans Integrated Service Network 22 Director ensures the VA San Diego Healthcare System Director takes steps such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetic Service operates in a manner that maximizes its resources to provide veterans with timely and cost effective fitting services compression garments and orthotic shoes.
3 The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements effective processes to monitor purchasing employees’ usage of all non item Healthcare Common Procedure Coding System codes to ensure the proper utilization of these codes.
4 The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements a process to examine the 4,530 consults closed, but not cloned, by purchasing employees using the NR018 code from October 2014 through May 2016 and take necessary action to ensure veterans received their prescribed prosthetic or orthotic item(s).
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| 17-05399-194 | Comprehensive Healthcare Inspection Program Review of the VA Hudson Valley Health Care System, Montrose, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that Facility clinical managers consistently initiate Focused Professional Practice Evaluations and that they are completed by providers with similar training and privileges and monitors compliance.
Closure Date:
2 The Associate Director ensures all required team members consistently participate on environment of care rounds and monitors compliance.
Closure Date:
3 The Associate Director ensures damaged or soiled furnishings and equipment in patient care areas are sanitized, repaired, or removed from service and monitors compliance.
Closure Date:
4 The Associate Director ensures that shower soap dispensers in the acute Mental Health Unit are replaced as required by the Mental Health Environment of Care Checklist and monitors compliance.
Closure Date:
5 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:
6 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Closure Date:
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| 18-00609-185 | Comprehensive Healthcare Inspection Program Review of the Memphis VA Medical Center | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures Facility staff enter all patient incidents into WebSPOT or the VHA Patient Safety Information System and monitors compliance.
Closure Date:
2 The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations on all newly hired Licensed Independent Providers and monitors compliance
Closure Date:
3 The Chief of Staff ensures that service chiefs include review of relevant data in Ongoing Professional Practice Evaluations to determine continuation of current privileging for Licensed Independent Providers and monitors 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 Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
Closure Date:
6 The Associate Director ensures that bottom shelves in equipment storage areas are solid or have impervious shelf liners and monitors compliance.
Closure Date:
7 The Associate Director ensures clinical staff remove expired medications from patient care areas and monitors compliance.
Closure Date:
8 The Associate Director ensures the Facility managers maintain a safe and clean environment at the Covington North Community Based Outpatient Clinic and monitors compliance.
Closure Date:
9 The Associate Director ensures that Community Based Outpatient Clinic staff maintain clear means of egress at the Covington North Community Based Outpatient Clinic and monitors compliance.
Closure Date:
10 The Associate Director ensures that environmental management service staff maintain clean air ducts and ventilation grills in food service and storage areas and monitors compliance.
Closure Date:
11 The Facility Director ensures the Controlled Substance Coordinator completes and documents annual controlled substance inspector training and monitors compliance.
Closure Date:
12 The Chief of Staff ensures that Geriatric and Extended Care Service leaders conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitors compliance.
Closure Date:
13 The Associate Director for Patient Care Services ensures that all staff involved in managing central lines receive central line-associated bloodstream infection prevention education 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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15169