Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01854-115 | Comprehensive Healthcare Inspection Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
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2 The Facility Director ensures inter-facility patient transfer data are collected and reported to the Medical Executive Committee and monitors compliance.
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3 The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently include documentation of patient or surrogate informed consent and identification of transferring and receiving provider or designee in transfer documentation and monitors the clinicians’ compliance.
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4 The Chief of Staff ensures that transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitors acceptable designees’ compliance.
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5 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.
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6 The Deputy Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
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7 The Deputy Director ensures core team members consistently attend environment of care rounds and monitors compliance.
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8 The Deputy Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on the identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
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9 The Chief of Staff ensures staff who perform, assist with, or supervise moderate sedation procedures have current Talent Management System moderate sedation training and monitors their compliance.
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10 The Associate Director for Patient Care Services ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors the social workers’ and registered nurses’ compliance.
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| 16-04655-70 | Audit of VISN 7 Power Wheelchair and Scooter Repairs | Audit | ||
1 The OIG recommended the Veterans Integrated Service Network 7 Director require VA medical facility staff to input power wheelchair and scooter repair requests as soon as they are received and implement management controls to ensure repairs with closed consults are monitored to completion.
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2 The OIG recommended the Veterans Integrated Service Network 7 Director ensure Prosthetic Service staff follow documentation procedures by making annotations in the consults as required by Veterans Health Administration Directive 1232(1), Consult Processes and Procedures, and the Prosthetic and Sensory Aids Service Business Practice Guidelines for Prosthetics Consult Management for power wheelchair and scooter repair.
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3 The OIG recommended the Veterans Integrated Service Network 7 Director implement controls to ensure Prosthetic Service staff monitor and follow up on repairs from initial request through completion to ensure the repairs are timely.
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4 The OIG recommended the Veterans Integrated Service Network 7 Director ensure Prosthetic Service managers and staff monitor vendors to ensure they meet agreed-upon delivery dates for repairs.
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| 17-00481-117 | Audit of Veteran Wait Time Data, Choice Access, and Consult Management in VISN 15 | Audit | ||
1 The OIG recommended the Veterans Integrated Service Network 15 Director ensure that staff at all network facilities use the clinically indicated date, when available, when scheduling new patient appointments.
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2 The OIG recommended the Veterans Health Administration Executive in Charge initiate a process to automate the use of the clinically indicated date, when applicable, when scheduling appointments.
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3 The OIG recommended the Veterans Integrated Service Network 15 Director ensure network facilities appropriately manage the scheduler audit tool in order to conduct the required scheduler audits, communicate specific audit results to scheduling staff, and take corrective actions as needed based on audit results.
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4 The OIG recommended the Veterans Integrated Service Network 15 Director examine processes to improve monitoring and tracking for timely surveillance colonoscopies.
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5 The OIG recommended the Veterans Integrated Service Network 15 Director implement additional standard monitoring procedures sufficient to enable network facility staff to accurately manage the aging of all referrals for eligible veterans for Choice care.
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6 The OIG recommended the Veterans Health Administration Executive in Charge implement standard monitoring procedures to ensure medical appointment timeliness standards are met as required under Choice contracts.
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7 The OIG recommended the Veterans Health Administration Executive in Charge implement controls to ensure Choice medical documentation is received timely in accordance with Choice contracts.
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8 The OIG recommended the Veterans Integrated Service Network 15 Director communicate specific audit results of VHA’s audit of consults to all network facility staff involved in consult management, implement specific training, and ensure corrective action is taken as needed.
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9 The OIG recommended the Veterans Integrated Service Network 15 Director ensure network facilities manage consults that are clinically indicated for the future in accordance with VHA’s consult policy.
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10 The OIG recommended the Veterans Integrated Service Network 15 Director ensure network facilities implement contingency plans in accordance with VHA’s outpatient clinic practice management policy and communicate to providers regarding how to process consults when a service becomes unavailable.
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11 The OIG recommended the Veterans Integrated Service Network 15 Director ensure the care of patients identified in the patient summaries of this report are evaluated, take action, if appropriate, and confer with Regional Counsel regarding the appropriateness of disclosures to patients and families.
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| 17-01485-128 | Healthcare Inspection – Mismanagement of Resuscitation and Other Concerns at the Buffalo VA Medical Center, Buffalo, New York | Hotline Healthcare Inspection | ||
1 We recommended that the VA Office of the General Counsel, pursuant to VA Directive 6311, work in conjunction with the Office of Information Technology, Veterans Health Administration offices, and other interested offices to advise the Under Secretary for Health regarding the refinement (or development) of policies reasonably designed to ensure the preservation of electronically stored information when legally necessary (or desirable for purposes of quality improvement), including, but not limited to electronically stored information that is subject to auto-deletion, such as telemetry data.
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2 We recommended that the Veterans Integrated Service Network Director conduct an evaluation of the Facility’s quality management practices (including but not limited to Root Cause Analyses, Issue Briefs, Administrative Investigation Boards, and Institutional Disclosures) to ensure that they align with Veterans Health Administration policies and also address the following specific deficiencies in this case: (a) the failure to conduct a Root Cause Analysis, (b) the failure to conduct a timely Administrative Investigation Board, (c) the failure to provide an Issue Brief, (d) the failure of the Administrative Investigation Board to consider all available evidence, and (e) the failure to make an Institutional Disclosure consistent with Veterans Health Administration Policy.
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3 We recommended that the Facility Director review the care of the patient who is the subject of this report and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
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4 We recommended that the Facility Director ensure that staff conduct interprofessional mock code training throughout the Facility with debriefing and monitor outcomes.
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5 We recommended that the Facility Director conduct an evaluation inclusive of, but not limited to, unit 9B and the Respiratory Department to determine if there are issues undermining teamwork at the work place, take action to address those issues, and monitor compliance.
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6 We recommended that the Facility Director ensure that staff adhere to the Facility’s telemetry policy including, but not limited to, saving rhythm strips when a patient has a change in his/her baseline or a significant arrhythmia, that a competent staff member is always at the telemetry station, and that facility managers monitor compliance.
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7 We recommended that the Facility Director ensure that the Facility’s Education Department staff review the adequacy of its annual telemetry monitoring re-certification process including, but not limited to, evaluating whether to institute additional requirements for staff who rarely have practical experience in telemetry monitoring and establishing procedures to ensure that re-tests are conducted and tracked appropriately and monitor compliance.
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8 We recommended that the Facility Director evaluate the Respiratory Department handoff communications process including the timing of patients’ treatments and code status and modify as appropriate.
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9 We recommended that the Facility Director ensure staff assess patients before and after breathing treatments, document the patient’s response in the electronic health record, and monitor compliance.
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10 We recommended that the Facility Director review the content of Facility staff’s communication to the patient’s family and take corrective action if it is determined that the communication was insufficient to convey that the Facility was disclosing potentially inadequate care.
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| 17-02686-125 | Healthcare Inspection – Alleged Patient Aligned Care Team Wait Time and Funding Issues at the Monterey Community Based Outpatient Clinic, VA Palo Alto Health Care System, Palo Alto, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director review human resources and clinic hiring processes for Patient Aligned Care Team staff and take action to minimize delays in filling vacancies.
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2 We recommended that the System Director assess and ensure patient panel sizes for Patient Aligned Care Team providers are in compliance with Veterans Health Administration policy.
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3 We recommended that the System Director ensure that Patient Aligned Care Team process improvement projects do not negatively affect clinic patient appointments.
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| 17-02644-130 | Critical Deficiencies at the Washington DC VAMC | Hotline Healthcare Inspection | ||
1 The Medical Center Director ensures that necessary supplies, instruments, and equipment are available in patient care areas at the Medical Center when and where they are needed.
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2 The Medical Center Director requires operating room staff to conduct the final validation that all supplies, instruments, and equipment needed to perform the planned procedure and to address potential complications are in the operating room and available for use.
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3 The Medical Center Director makes certain that the OR staff have accurate lists of surgical instruments needed for particular procedures.
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4 The Under Secretary for Health specifies criteria under which individual medical centers will conduct wild card Aggregated Reviews for high-frequency patient safety events.
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5 The Medical Center Director ensures that routine audits of incident reporting system entries are completed to ascertain that all patient safety events are in the National Center for Patient Safety database as required by VHA policy.
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6 The Medical Center Director requires Medical Center oversight committees to follow up and initiate action as necessary on quality assurance matters related to supplies, instruments, or equipment.
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7 The Medical Center Director confirms the full utilization of a VHA authorized inventory system that contains accurate and reliable information regarding the availability of supplies throughout the Medical Center.
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8 The Medical Center Director makes certain that the environmental integrity of clean/sterile storerooms complies with VHA policy.
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9 The Medical Center Director ensures there are clearly defined and effective procedures for replacing missing or broken instruments, and that staff responsible for this function have been educated on the process.
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10 The Medical Center Director confirms that clearly defined and effective procedures address the disposition of discolored instruments during reprocessing and that staff responsible for this function have been educated on the process.
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11 The Medical Center Director ensures that the Sterile Processing Service (SPS) implements a quality assurance program to verify the cleanliness, functionality, and completeness of instrument sets prior to their reaching clinical areas.
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12 The Medical Center Director makes certain that SPS and OR personnel comply with policies and procedures for the proper reprocessing of loaner instruments and trays.
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13 The Medical Center Director verifies that SPS managers maintain an accurate Master List for reusable medical equipment and file copies of manufacturer’s instructions as required by VHA policy.
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14 The Medical Center Director ensures that the SPS maintains updated and readily accessible standard operating procedures for all instruments and equipment within SPS and its satellite areas in accordance with VHA policy.
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15 The Medical Center Director verifies that all SPS employees have appropriate, updated competencies and a demonstrated proficiency to perform their assigned duties.
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16 The VISN 5 Director secures adequate space and funding for the Medical Center satellite reprocessing areas, which includes separate decontamination, processing, and packaging areas in accordance with VHA SPS policies.
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17 The VISN 5 Director makes certain that the Medical Center Director resolves open and pending prosthetic consults and implements a plan to address future prosthetic consults in accordance with VHA policy.
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18 The Medical Center Director ensures the revision of Medical Center Fiscal Service practices to eliminate unnecessary cessations of prosthetic device purchasing, including at fiscal year-end.
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19 The VISN 5 Director, together with Medical Center leaders, develops a staffing plan to fill vacancies that includes accurate numbers of authorized positions by service that is based on clinical and administrative workload and other appropriate measures, and includes contingencies for staffing areas with high attrition rates.
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20 The VISN 5 Director ensures the timely completion of hiring actions at the Medical Center until staffing deficiencies in Logistics Service and Sterile Processing Services are fully resolved.
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21 The Medical Center Director transitions purchase cards held by clinical staff and used for expendable medical supplies to Logistics Service staff, while ensuring that medical supplies can be obtained in a timely manner.
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22 The Medical Center Director ensures that medical supply items are added to the prime vendor formulary in order to meet prime vendor purchasing goals.
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23 The Medical Center Director makes certain that the Purchase Card Coordinator and approving officials monitor the issuance and future use of government purchase cards in accordance with VA Financial Policy.
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24 The Medical Center Director maintains segregation of duties between personnel who order and purchase expendable and nonexpendable items and those who receive the items.
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25 The VISN 5 Director ensures that the Medical Center updates and maintains the Equipment Inventory List (EIL) as required by VA policy and makes certain that the Medical Center Director and Chief Logistics Officer are held accountable for the timely and accurate reporting of the Medical Center EIL.
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26 The Medical Center Director ensures that equipment is accurately and timely entered into the Automated Engineering Management System/Medical Equipment Reporting System.
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27 The Medical Center Director ensures that unrequired equipment is turned in for disposition consistent with VHA policies and procedures
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28 The Medical Center Director properly secures all areas used to store medical equipment and supplies.
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29 The Medical Center Director designates an official records manager, alternate records manager, and official records liaisons, as well as implements a records management program in accordance with the National Archives and Records Administration requirements.
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30 The Medical Center Director verifies that actions have been taken to notify patients when their information may have been improperly accessed, as appropriate.
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31 The Medical Center Director verifies that accurate and complete financial documentation to support medical supply and equipment purchases is readily available in accordance with GAO Standards for Internal Control in the Federal Government.
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32 The VISN 5 Director audits a representative sample of FY 2017 Medical Center supply, instrument, and equipment purchases and ensures adequate internal controls for future purchases are in place.
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33 The Deputy Under Secretary for Health for Operations and Management ensures that the VHA Procurement and Logistics Office conducts regular audits of the logistics services within VHA medical centers to assess compliance with VA and VHA policies pertaining to procurement and logistics, and makes certain that timely and effective remediation occurs in response to all noncompliant conditions identified as a result of those audits.
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34 The VISN 5 Director evaluates the accuracy of representations made by Medical Center staff in connection with the completion of action plans arising out of the National Program Office of Sterile Processing October 2016 site visit and determines whether administrative actions should be taken as a result of those representations.
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35 The VISN 5 Director institutes procedures designed to ensure the accuracy of future representations made by Washington DC VA Medical Center staff in connection with action plans submitted to oversight bodies such as VHA program offices.
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36 The Under Secretary for Health clearly defines program offices’ responsibility for reporting high-priority recommendations to responsible individuals within VHACO, and requires independent verification that the relevant medical center and/or VISN have implemented the recommendations.
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37 The Under Secretary for Health develops a means of aggregating and analyzing available data on Logistics, Sterile Processing, Prosthetics, and Human Resources services (or other services as the Under Secretary for Health deems appropriate) so that major operational deficiencies at a medical center or VISN that affect multiple services or functions may be detected and corrected.
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38 The Under Secretary for Health takes appropriate administrative action to address the conditions identified in this report.
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39 The VISN 5 Director oversees implementation of recommendations directed to the Medical Center Director.
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40 The Under Secretary for Health verifies the successful implementation of all recommendations contained within this report.
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| 16-00409-64 | Audit of Interior Design and Furnishing Contract Mismanagement by Network Contracting Office 21 | Audit | ||
1 The OIG recommended Service Area Office West Executive Director ensure the Network Contracting Office 21 Director implements the required integrated oversight process to perform the required pre-award contract reviews to ensure contracting officers’ compliance with Federal and VA acquisition regulations prior to contract award.
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2 The OIG recommended the Veterans Integrated Service Network 21 Director consult with the appropriate VA financial and legal officials to determine steps the Northern California Health Care System Director should take to remedy the violation of the bona fide needs rule.
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3 The OIG recommended the Service Area Office West Executive Directortake steps to ensure the Network Contracting Office 21 Director developand implement processes to effectively monitor the status of contractsand ensure contracting officers appropriately modify the contracts orclose them out in accordance with contract terms and the FederalAcquisition Regulation.
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| 17-01491-112 | Healthcare Inspection—Quality of Care and Patient Safety Concerns in the Community Living Center, James A. Haley VA Hospital, Tampa, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that Community Living Center and Emergency Department staff understand and comply with policies for communication about residents requiring evaluation and treatment.
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2 We recommended that the Facility Director ensure that Community Living Center leaders develop a system to ensure fall precautions identified in the Falls Assessment are consistently reflected in the Individual Care Plan and implemented accordingly, and that staff are held accountable.
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3 We recommended that the Facility Director ensure the availability and functionality of fall prevention and safety devices such as hip protectors and chair alarms.
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4 We recommended that the Facility Director ensure that Community Living Center leaders follow through on efforts to determine staff knowledge deficits related to fall prevention and institute training and process improvements.
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5 We recommended that the Facility Director ensure that Community Living Center leaders conduct appropriate reviews and implement required actions in cases of suspected abuse or neglect.
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6 We recommended that the Facility Director ensure an adequate nurse staffing mix to meet the acuity levels and needs of the Community Living Center’s residents.
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| 17-01746-116 | Comprehensive Healthcare Inspection Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures that a senior-level committee is established and responsible for key Quality, Safety, and Value functions.
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2 The Facility Director ensures the Patient Safety Manager completes the required minimum of eight root cause analyses each fiscal year and monitors the manager’s compliance.
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3 The Chief of Staff ensures that anticoagulation management program quality assurance data are analyzed and reported to the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.
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4 The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians' compliance.
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5 The Chief of Staff ensures clinicians consistently obtain and document all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians' compliance.
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6 The Chief of Staff ensures all required elements specific to anticoagulation management are included in competency assessments for employees actively involved in the anticoagulant program and monitors compliance.
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7 The Associate Director ensures environment of care inspections are conducted at the required frequency and monitors compliance.
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8 The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
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9 The Chief of Staff and the Nurse Executive ensure that the Community Nursing Home Oversight Committee includes representation by all required disciplines and monitor compliance
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10 The Nurse Executive ensures social workers conduct cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitors social workers’ compliance.
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| 17-01758-104 | Comprehensive Healthcare Inspection Program Review of the Hampton VA Medical Center, Hampton, Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that clinical managers communicate to the Peer Review Committee all completions of individual improvement actions and monitors managers’ compliance.
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2 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data with the frequency required by facility policy and monitors the managers’ compliance.
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3 The Chief of Staff requires clinicians to ensure patients with newly prescribed warfarin have international normalized ratio measurements taken within 7 days of warfarin initiation, and monitor compliance.
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4 The Chief of Staff requires clinical managers to complete competency assessments annually for employees actively involved in the anticoagulant program and monitors managers’ compliance.
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5 The Chief of Staff ensures clinicians consistently include identification of the receiving provider in transfer documentation and monitors the clinicians’ compliance.
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6 The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
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7 The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
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8 The Associate Director ensures the Chesapeake community based outpatient clinic panic alarms are tested monthly and monitors compliance.
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9 The Associate Director ensures storage carts and shelves at the Chesapeake Community Based Outpatient Clinic have solid bottom shelves and monitors compliance.
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10 The Associate Director ensures locked mental health unit panic alarm testing includes documentation of VA Police response time and monitors compliance.
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11 The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.
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12 The Associate Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training for identification and correction of environmental hazards and proper use of the Mental Health Environment of Care Checklist and monitors compliance.
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13 The Chief of Staff ensures providers include a history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and monitors providers’ compliance.
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14 The Chief of Staff ensures that physicians who perform or assist with moderate sedation procedures receive training for the provision of moderate sedation care prior to being re-privileged and that training is documented and monitors compliance with training and documentation.
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15 The Facility Director ensures that the Community Nursing Home Oversight Committee meets at least quarterly, includes representatives from all required disciplines, and integrates processes into the facility’s quality improvement program with documentation of these processes in the facility’s executive-level committee meeting minutes and monitors compliance.
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16 The Chief of Staff ensures the Community Nursing Home Review Team completes annual reviews within the required timeframe and submits exclusionary criteria exemption requests when a community nursing home meets the threshold of four or more deficiencies and monitors the team’s compliance.
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17 The Chief of Staff ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors social workers’ and registered nurses’ compliance.
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18 The Associate Director ensures that Domiciliary Care for Homeless Veterans Program, general domiciliary, and Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees conduct and document daily resident room inspections for unsecured medications and monitors employees’ compliance.
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19 The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.
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