Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00550-32 | Healthcare Facility Inspection of the VA Chillicothe Healthcare System in Ohio | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders ensure staff understand procedures for cleaning equipment and continue to monitor the physical separation of clean and dirty items in storage spaces.
2 The OIG recommends that primary care leaders incorporate feedback from primary care staff and include them in process improvement projects.
Closure Date:
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| 24-00390-41 | Inspection of Pacific District 5 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director, in conjunction with the Deputy District Director, develops a contingency coverage plan to ensure oversight during periods of vet center director vacancies.
Closure Date:
2 The District Director monitors district leaders’ compliance with completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.
Closure Date:
3 The District Director ensures district leaders are aware of the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review completion, including panel member assignments, participation of affected vet center staff, report completion, reporting of completion delays, and information dissemination.
4 The District Director determines reasons vet center counselors did not complete safety plan components for clients assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures completion of safety plans for all active clients assessed at intermediate or high suicide risk levels; and monitors compliance across all zone vet centers.
5 The District Director determines reasons staff did not document providing safety plans to clients, ensures all active clients assessed at intermediate or high suicide risk levels receives a safety plan, and monitors compliance across all zone vet centers.
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| 24-01623-30 | Improvement in the Patient Safety Program with Continued Opportunities to Strengthen Veterans Integrated Service Network 7 Oversight at the Tuscaloosa VA Medical Center in Alabama | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director confirms that the patient safety officer reviews investigations by subject matter experts for Joint Patient Safety Reporting events.
2 The Veterans Integrated Service Network Director provides evidence to demonstrate the Patient Safety Office is completing reviews of a sample of patient safety events that includes analysis of content, recommendations, and required actions, as outlined in Veterans Health Administration Directive 1050.01.
3 The Veterans Integrated Service Network Director ensures that the Veterans Integrated Service Network 7 Quality and Patient Safety Committee minutes reflect that the patient safety officer conducted analysis of patient safety data to identify opportunities for improvement and provided guidance on facilities’ action plans to address the deficiencies.
Closure Date:
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| 24-00588-19 | Healthcare Facility Inspection of the Birmingham VA Health Care System in Alabama | Healthcare Facility Inspection | ||
1 The OIG recommends that Veterans Integrated Service Network leaders ensure facility staff separate clean and dirty equipment and supplies to prevent cross-contamination.
2 The OIG recommends Veterans Integrated Service Network leaders ensure facility staff keep the environment clean and safe.
3 The OIG recommends that executive leaders ensure front desk personnel are competent in communicating with sensory-impaired veterans.
4 The OIG recommends that facility leaders consistently identify opportunities for improvement, ensure staff implement appropriate action plans, and evaluate actions for sustained improvement.
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| 23-02939-13 | Inadequate Staff Training and Lack of Oversight Contribute to the Veterans Health Administration’s Suicide Risk Screening and Evaluation Deficiencies | National Healthcare Review | ||
1 The Under Secretary for Health ensures that required suicide risk and intervention training includes suicide risk identification screening and evaluation requirements, procedures, and instruction.
2 The Under Secretary for Health considers establishing benchmarks for suicide risk screening and evaluation that reflect the clinical importance of suicide risk identification requirements and takes action as warranted.
3 The Under Secretary for Health ensures monitoring of adherence to suicide risk identification screening and evaluation setting-specific requirements.
4 The Under Secretary for Health ensures actions taken to address barriers to completing suicide risk screening and evaluation are effective to increase adherence to annual and setting-specific requirements in all clinical settings.
5 The Under Secretary for Health ensures non-mental health clinical specialty leaders are aware of and adherent to the suicide risk identification screening and evaluation requirements.
6 The Under Secretary for Health ensures clearly identified responsibilities for suicide risk identification screening and evaluation adherence monitoring and oversight.
Closure Date:
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| 21-02389-23 | Deficiencies in Inpatient Mental Health Suicide Risk Assessment, Mental Health Treatment Coordinator Processes, and Discharge Care Coordination | National Healthcare Review | ||
1 The Under Secretary for Health monitors inpatient mental health unit adherence to suicide risk identification processes and identifies and addresses barriers.
2 The Under Secretary for Health ensures inpatient mental health unit staff complete suicide prevention safety plans as expected, and monitors compliance.
3 The Under Secretary for Health clarifies requirements for facility-level written guidance regarding the processes for mental health treatment coordinator identification, assignment, and care coordination, and monitors compliance.
4 The Under Secretary for Health ensures accurate and timely mental health treatment coordinator assignment, including patient centered management module entry and notification for the assigned staff and applicable patient.
5 The Under Secretary for Health evaluates the effectiveness of dedicated mental health treatment coordinators in enhancing patient engagement in outpatient mental health care following discharge from an inpatient mental health unit, and takes action as appropriate.
6 The Under Secretary for Health considers establishing written guidance regarding expectations for mental health unit staff to schedule patients’ post-discharge mental health care appointments.
Closure Date:
7 The Under Secretary for Health determines supportive factors that contribute to patients’ attendance at outpatient mental health appointments following discharge from an inpatient mental health unit, including self-motivation enhancement and family and friend involvement, and takes action to integrate such factors into discharge planning procedures.
Closure Date:
8 The Under Secretary for Health considers establishing a process for patient orientation to the behavioral health interdisciplinary team to facilitate patient awareness of, and accessibility to, team members, and takes action as appropriate.
Closure Date:
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| 24-00704-21 | Allegation of Underutilization of Mental Health Clinics, and Concern for Delays in Patient Care, at the Hinesville VA Clinic in Georgia | Hotline Healthcare Inspection | ||
1 The Ralph H. Johnson VA Health Care System Director ensures optimal mental health clinic utilization at the Hinesville VA Clinic.
Closure Date:
2 The Ralph H. Johnson VA Health Care System Director ensures that mental health Hinesville VA Clinic staff are using accurate current procedural terminology codes to document services provided to patients in the electronic medical record.
Closure Date:
3 The Ralph H. Johnson VA Health Care System Director confirms evaluation of administrative processes to include consult management and patient scheduling within the mental health service at the Hinesville VA Clinic and takes action as necessary to optimize patient access and experience.
Closure Date:
4 The Ralph H. Johnson VA Health Care System Director completes a review of the patients identified by the Office of Inspector General to have experienced a median wait time of at least three weeks between individual therapy sessions and takes action to resolve any patient care concerns identified during the review.
Closure Date:
5 The Ralph H. Johnson VA Health Care System Director considers evaluating the Choose My Therapy program at other system sites for clinic practice management deficiencies and takes action as appropriate.
Closure Date:
6 The Ralph H. Johnson VA Health Care System Director ensures that all patients listed in the electronic spreadsheet have received mental health follow-up care.
Closure Date:
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| 21-00524-25 | VHA Policy and Practice Support Age-Specific Osteoporosis Screening in Women | National Healthcare Review | ||
1 The Under Secretary for Health works with the Women’s Program Office to gain an understanding of barriers to osteoporosis clinical reminder use and based on results, implement action as needed.
Closure Date:
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| 24-00589-17 | Healthcare Facility Inspection of the VA Northport Healthcare System in New York | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders ensure staff secure all medications and the supplies used to administer medications in the Emergency Department.
Closure Date:
2 The OIG recommends facility leaders confirm staff are knowledgeable about how the lobby kiosks function to assist veterans with sensory impairments.
Closure Date:
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| 24-00586-11 | Healthcare Facility Inspection of the Durham VA Health Care System in North Carolina | Healthcare Facility Inspection | ||
1 The OIG recommends that executive leaders ensure staff store all high-alert medications in a secure or locked area.
Closure Date:
2 The OIG recommends that executive leaders ensure staff follow their processes to prevent the storage of expired medical supplies and that supply areas remain clean.
Closure Date:
3 The OIG recommends that executive leaders ensure staff keep the facility free of temporary signage that may interfere with cleaning and disinfection processes.
Closure Date:
4 The OIG recommends that the patient safety manager confirms staff enter known patient safety events into the Joint Patient Safety Reporting system for use in the initial assessment of these events.
Closure Date:
5 The OIG recommends that executive leaders ensure quality management staff implement an oversight process to validate providers’ compliance with patient communication and follow-up for urgent, noncritical abnormal test results.
Closure Date:
6 The OIG recommends executive leaders evaluate options to improve safety at the informal crossing area near parking garage B.
Closure Date:
7 The OIG recommends that executive leaders ensure all directories are accurate and provide specific details so veterans can easily navigate the facility.
Closure Date:
8 The OIG recommends that executive leaders implement additional features to aid veterans with sensory impairments to navigate the facility.
Closure Date:
9 The OIG recommends that executive leaders ensure staff train patient escorts on how to effectively communicate with sensory-impaired veterans.
Closure Date:
10 The OIG recommends that executive leaders ensure the Comprehensive Environment of Care Committee reviews environment of care deficiencies for trends and opportunities for improvement.
Closure Date:
11 The OIG recommends that executive leaders ensure staff review patient safety events for trends and system vulnerabilities and implement process improvement actions to prevent future occurrences.
Closure Date:
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15039