Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-01580-108 | Healthcare Inspection - Review of Montana Board of Psychologists Complaint and Assessment of VA Protocols for Traumatic Brain Injury Compensation and Pension Examinations | National Healthcare Review | ||
1 We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to ensure that personnel performing the traumatic brain injury Compensation and Pension examination have comprehensive training on the evaluation of traumatic brain injury, including the assessment and evaluation of cognitive disorders.
Closure Date:
2 We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to develop requirements for documentation of the traumatic brain injury Compensation and Pension examination process, including the basis for determinations of cognitive impairment and other residuals of traumatic brain injury.
Closure Date:
3 We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to consider whether to provide disability ratings to veterans with claims arising from cognitive issues based upon their clinical signs and symptoms, not primarily based upon the diagnosis or cause of their cognitive deficits (that is. traumatic brain injury or post-traumatic stress disorder).
Closure Date:
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| 17-02678-107 | Healthcare Inspection—Alleged Failure in Patient Notification of Test Results, VA Connecticut Healthcare System, West Haven, Connecticut | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure providers follow the Veterans Health Administration policy related to patient notification of test results.
Closure Date:
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| 17-01750-97 | Comprehensive Healthcare Inspection Program Review of the VA Northern California Health Care System, Mather, California | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures peer reviewers consistently use at least one of the important aspects of care to evaluate peer review findings and monitors reviewers’ compliance.
Closure Date:
2 The Chief of Staff ensures service chiefs consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the service chiefs’ compliance.
Closure Date:
3 The Chief of Staff ensures pharmacy managers implement an anticoagulation management standard operating procedure that contains all elements required by the Veterans Health Administration.
Closure Date:
4 The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians’ compliance.
Closure Date:
5 The Chief of Staff ensures clinical managers include all required elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
Closure Date:
6 The Chief of Staff ensures clinicians consistently include patient or surrogate informed consent in transfer documentation and monitors clinicians’ compliance.
Closure Date:
7 The Associate Directors ensure required team members participate on environment of care rounds and monitor compliance.
Closure Date:
8 The Associate Director ensures VA Police conduct required testing of the locked mental health unit security surveillance television system and monitors VA Police compliance.
Closure Date:
9 The Associate Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
10 The Chief of Staff ensures providers include the history of previous experience with sedation and anesthesia in the history and physical exams and/or pre-sedation assessments and monitors compliance.
Closure Date:
11 The Chief of Staff ensures clinical teams use a checklist that includes all required elements to conduct and document timeouts prior to moderate sedation procedures and monitors the teams’ compliance.
Closure Date:
12 The Chief of Staff ensures the Community Nursing Home Review Team completes required annual reviews and monitors the team’s compliance.
Closure Date:
13 The Chief of Staff ensures social workers and registered nurses conduct cyclical clinical visits with the frequency required and monitors social workers’ and registered nurses’ compliance.
Closure Date:
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| 17-05909-106 | Administrative Investigation – VA Secretary and Delegation Travel to Europe | Administrative Investigation | ||
1 Secretary Shulkin reimburses the $4,312 paid by VA to cover Dr. Bari’s travel costs.
Closure Date:
2 Secretary Shulkin consults with the Office of General Counsel to determine the value of the Wimbledon tickets; grounds pass; and any food, parking, and other tangible benefits Ms. Gosling provided in connection with Wimbledon and reimburse that amount to her. If Ms. Gosling declines to accept reimbursement, Secretary Shulkin reimburses such amount to the US Treasury.
Closure Date:
3 The Deputy Secretary of Veterans Affairs confers with the Offices of General Counsel, Human Resources, and Accountability and Whistleblower Protection to determine the appropriate administrative action to take, if any, against Ms. Wright Simpson and any other individuals associated with the Europe trip.
Closure Date:
4 The Deputy Secretary of Veterans Affairs ensures that a thorough audit is conducted of the expense vouchers, travel authorizations, and the time and attendance records for all travelers on the Europe trip. Any overpayments should be reimbursed to VA by the traveler and any required leave adjustments should be made. Detailed results of the audits, including supporting documentation, shall be provided to the Office of Inspector General no later than thirty days following the publication of this report.
Closure Date:
5 The Deputy Secretary of Veterans Affairs ensures that the Office of General Counsel (i) reviews and enhances the training provided to staff on travel planning, approvals, and the solicitation or acceptance of gifts; and (ii) provides refresher training on these topics to all travelers on the Europe trip as well as all staff involved in the planning and implementation of the trip.
Closure Date:
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| 17-03860-100 | Healthcare Inspection—Medical Foster Home Program Concerns, Chalmers P. Wylie VA Ambulatory Care Center, Columbus, Ohio | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health amends Medical Foster Home policy to include processes for reporting Medical Foster Home revocations to appropriate authorities to ensure current and future resident safety.
Closure Date:
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| 17-01756-86 | Comprehensive Healthcare Inspection Program Review of the Miami VA Healthcare System, Miami, Florida | 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.
Closure Date:
2 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:
3 The Facility Director ensures patient transfer data for transfers out of the facility are collected, analyzed, and reported to an identified quality oversight committee and monitors compliance.
Closure Date:
4 The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
Closure Date:
5 The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
Closure Date:
6 The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
Closure Date:
7 The Chief of Staff ensures that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record, and the Chief of Staff monitors providers’ compliance.
Closure Date:
8 The Chief of Staff ensures the Community Nursing Home Oversight Committee meets at least quarterly, includes representation by all required disciplines, and demonstrates integration with the facility quality improvement program, and the Chief of Staff monitors compliance.
Closure Date:
9 The Chief of Staff ensures the Community Nursing Home Review Team completes the required annual reviews for the community nursing homes and monitors managers’ compliance.
Closure Date:
10 The Chief of Staff ensures social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration and monitors compliance.
Closure Date:
11 The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program employees in units 5A and 5D conduct and document daily resident room inspections for unsecured medications and monitors compliance.
Closure Date:
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| 16-02695-51 | Review of Excessive Procurement Costs at VHA’s Rural Outreach Clinic in Laughlin, Nevada | Audit | ||
1 The OIG recommended the Executive in Charge, Veterans Health Administration, ensure required oversight reviews are conducted and documented prior to the award of leases, contracting officers perform acquisitions in accordance with Department of Veterans Affairs and Federal Acquisition Regulation requirements, and awarded lease rates are in the best interest of the government.
Closure Date:
2 The OIG recommended the Executive in Charge, Veterans Health Administration, ensure the lease for the Laughlin Rural Outreach Clinicis is reevaluated to determine the financial advantages and disadvantages of renegotiating the terms of the contract to obtain a Fair Rental Value commensurate with the Laughlin Nevada area.
Closure Date:
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| 17-01745-96 | Comprehensive Healthcare Inspection Program Review of the VA Black Hills Health Care System, Fort Meade, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures inter-facility patient transfer data are analyzed and reported to a quality oversight committee as part of the facility’s quality management program and monitors compliance.
Closure Date:
2 The Associate Director ensures required team members participate in environment of care rounds and monitors compliance.
Closure Date:
3 The Associate Director ensures the locked mental health unit’s seclusion room bed is secured to the floor.
Closure Date:
4 The Associate Director ensures that locked mental health unit employees and members of the Interdisciplinary Safety Inspection Team complete the required training for the identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and the Associate Director monitors compliance.
Closure Date:
5 The Chief of Staff ensures that providers assess for patients’ previous adverse experiences with sedation or anesthesia prior to performing moderate sedation procedures and monitors compliance.
Closure Date:
6 The Chief of Staff ensures that clinical team members conduct timeouts using a checklist with all the required elements prior to performing moderate sedation procedures and monitors compliance.
Closure Date:
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| 17-01762-88 | Comprehensive Healthcare Inspection Program Review of the VA New York Harbor Healthcare System, New York, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures Medicine Service clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
Closure Date:
2 The Chief of Staff ensures quality assurance data for the anticoagulation management program are collected, analyzed, and reported quarterly at Pharmacy and Therapeutics Committee meetings and monitors compliance.
Closure Date:
3 The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and refer patients prescribed direct-acting oral anticoagulants to the anticoagulation clinic and monitors clinicians’ compliance.
Closure Date:
4 The Chief of Staff requires that clinical managers include in the competency assessments of employees actively involved in the anticoagulant program knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy, and the Chief of Staff monitors clinical managers’ compliance.
Closure Date:
5 The Chief of Staff ensures inter-facility patient transfer data are analyzed and reported and monitors compliance.
Closure Date:
6 The Chief of Staff ensures that for patients transferred out of the facility, providers consistently complete VA Forms 10-2649A and 10-2649B as required by Veterans Integrated Service Network policy and monitors providers’ compliance.
Closure Date:
7 The Chief of Staff ensures that for patients transferred out of the facility, providers communicate with or send to the accepting facility pertinent patient information, and the Chief of Staff monitors providers’ compliance.
Closure Date:
8 The Associate Director for Facilities and Human Resources ensures the VA Police Service consistently participates on environment of care rounds and monitors compliance.
Closure Date:
9 The Associate Director for Facilities and Human Resources ensures locked mental health unit panic alarm testing documentation includes VA Police Service response time and monitors compliance.
Closure Date:
10 The Associate Director for Patient Care Services ensures that a risk assessment is completed when a locked mental health unit patient is using an electrical or mechanical hospital bed and that the room containing the bed is locked when not in use, and the Associate Director for Patient Care Services monitors compliance.
Closure Date:
11 The Facility Director ensures all members of the Interdisciplinary Safety Inspection Team complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and the Facility Director monitors compliance.
Closure Date:
12 The Chief of Staff ensures that the use of reversal agents in moderate sedation cases and the presence or absence of adverse events for all areas administering moderate sedation are reported to and trended by the Surgical, Procedural, Operative, and Therapeutic Committee and monitors compliance.
Closure Date:
13 The Chief of Staff ensures providers include a review of abnormalities of major organ systems; an airway assessment; and a review of alcohol, tobacco, or substance use or abuse in the history and physical exams and/or pre-sedation assessments and monitors providers’ compliance.
Closure Date:
14 The Chief of Staff ensures providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and monitors providers’ compliance.
Closure Date:
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| 17-01748-82 | Comprehensive Healthcare Inspection Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures revision of local policy to specify the Quality and Performance Council as the senior-level committee responsible for key quality, safety, and value functions and co-chairs this committee.
Closure Date:
2 The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors physician advisors’ compliance.
Closure Date:
3 The Chief of Staff ensures that anticoagulation management program quality assurance data are collected, analyzed, and reported quarterly at the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.
Closure Date:
4 The Chief of Staff ensures clinical managers include anticoagulation-specific elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
Closure Date:
5 The Facility Director ensures inter-facility patient transfer data are collected, reported, and analyzed as part of the facility’s quality management program and monitors compliance.
Closure Date:
6 The Chief of Staff ensures transfer notes written by acceptable designees include a staff/attending physician countersignature and monitors acceptable designees’ compliance.
Closure Date:
7 The Associate Director ensures required team members consistently participate in environment of care rounds and monitors team members’ compliance.
Closure Date:
8 The Associate Director ensures that VA Police perform and document system-wide panic alarm testing at the Salina community based outpatient clinic and monitors compliance.
Closure Date:
9 The Chief of Staff ensures providers include an airway assessment in the history and physical examination and/or pre-sedation assessment and monitors providers’ compliance.
Closure Date:
10 The Chief of Staff ensures clinicians perform post-procedure assessments of patient pain level and monitors clinicians’ compliance.
Closure Date:
11 The Facility Director ensures the Community Nursing Home Oversight Committee continues to meet at least quarterly and monitors compliance.
Closure Date:
12 The Facility Director ensures that the community nursing home program is integrated into the facility quality improvement program.
Closure Date:
13 The Chief of Staff ensures the Community Nursing Home Review Team completes required annual reviews and monitors the team’s compliance.
Closure Date:
14 The Chief of Staff and Associate Director for Patient Care Services ensure 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 monitor social workers’ and registered nurses’ compliance.
Closure Date:
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15169