Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-03288-362 | Healthcare Inspection—Inconsistent Transfer Procedures for Urgent Care Clinic Patients with Stroke Symptoms, Manchester VA Medical Center, Manchester, New Hampshire | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that Urgent Care Clinic providers consistently transfer stroke patients to an appropriate acute care facility in accordance with Veterans Health Administration and facility policies and procedures.
Closure Date:
2 We recommended that the Facility Director ensure that the Peer Review Committee follows Veterans Health Administration policy.
Closure Date:
3 We recommended that the Facility Director ensure that facility managers clinically review the records of the 13 patients not transferred to the non-VA acute care hospital, approximately 2.5 miles away, to determine whether patient harm occurred and take action as appropriate.
Closure Date:
| ||||
| 17-00970-327 | Inspection of VA Regional Office Wilmington, Delaware | Review | ||
1 We recommended the Wilmington VA Regional Office Director implement a plan to assess the effectiveness of second-signature reviews for Special Monthly Compensation and Ancillary Benefits claims.
Closure Date:
2 We recommended the Wilmington VA Regional Office Director implement plans to ensure the effectiveness of training conducted on processing claims for higher-level Special Monthly Compensation and Ancillary Benefits.
Closure Date:
3 We recommended that the Wilmington VA Regional Office Director implement a plan to ensure management provides a consistent quality review process which addresses all elements required when establishing claims in the electronic record and monitor the effectiveness of that plan.
Closure Date:
| ||||
| 16-02526-358 | Healthcare Inspection – Physical Medicine and Rehabilitation Services Consult Process Concerns, Central Texas Veterans Health Care System, Temple, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that consult clinical reviews and appointment scheduling for patients are conducted in compliance with Veterans Health Administration directives and system policies.
Closure Date:
2 We recommended that Physical Medicine and Rehabilitation Services have sufficient staffing to arrange for timely consultations and appointments within the service.
Closure Date:
3 We recommended that the Facility staff who schedule Physical Medicine and Rehabilitation Services patient appointments receive annual scheduling competencies to ensure understanding of the correct process for compliance with Veterans Health Administration directives and staff are monitored for compliance.
Closure Date:
| ||||
| 17-01354-336 | Inspection of Denver VA Regional Office | Review | ||
1 We recommended the Denver VA Regional Director implement a plan to complete proposed rating reduction cases at the end of the due process period.
Closure Date:
2 We recommended that the Denver VA Regional Office Director implement a plan to ensure all claims processing staff receive formal training on claims establishment procedures and monitor the effectiveness of that training.
Closure Date:
3 We recommended the Denver VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is reviewed for accuracy.
Closure Date:
4 We recommended the Denver VA Regional Office Director implement a plan to update the checklist used to evaluate quality at the time of claims establishment.
Closure Date:
| ||||
| 15-00650-353 | Healthcare Inspection – Delays in Scheduling Diagnostic Studies and Other Quality of Care Concerns, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that outpatient echocardiography and stress test consult requests are scheduled and completed in accordance with Veterans Health Administration policy.
Closure Date:
2 We recommended that the Facility Director ensure that sleep study consult requests are scheduled and completed within the timeframe required by Veterans Health Administration policy.
Closure Date:
3 We recommended that the Facility Director ensure that patients’ cardiac diagnostic and procedure reports are signed within the timeframe specified by policy to ensure appropriate follow-up and patient care coordination.
Closure Date:
| ||||
| 17-01276-300 | Inspection of the VA Regional Office Philadelphia, Pennsylvania | Review | ||
1 We recommended the Philadelphia VA Regional Office Director develop and implement a plan to assess the accuracy of secondary reviews involving higher-level Special Monthly Compensation and ancillary benefits.
Closure Date:
2 We recommended the Philadelphia VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.
Closure Date:
3 We recommended the Philadelphia VA Regional Office Director implement a plan to assess the effectiveness of the most recent claims establishment training.
Closure Date:
4 We recommended the Philadelphia VA Regional Office Director provide training on special controlled correspondence to ensure accurate and complete responses to the veteran and Congressional staff, and monitor the effectiveness of the training.
Closure Date:
5 We recommended the Philadelphia VA Regional Office Director improve oversight of special controlled correspondence.
Closure Date:
| ||||
| 15-03418-350 | Healthcare Inspection: Patient Flow, Quality of Care, and Administrative Concerns in the Emergency Department, VA Maryland Health Care System, Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that VA Maryland Health Care System managers strengthen patient flow processes.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director ensure that VA Maryland Health Care System managers evaluate staff's Emergency Department Integrated Software data entry and implement action plans to ensure data accuracy and timeliness.
Closure Date:
3 We recommended that the Veterans Integrated Service Network Director ensure that the VA Maryland Health Care System managers strengthen Patient Flow Committee processes to include the establishment of patient flow goals, action target dates, and oversight of action implementation.
Closure Date:
4 We recommended that the System Director ensure that policy regarding patients boarding in the Emergency Department include all required elements.
Closure Date:
5 We recommended that the System Director strengthen Bed Management Solution utilization and processes, and monitor compliance.
Closure Date:
6 We recommended that the System Director strengthen processes to improve timeliness of bed cleaning.
Closure Date:
7 We recommended that the System Director review the impact of inpatient medicine admission capping and establish alternative plans that improve patient flow from the Emergency Department, monitor outcomes, and implement alternative plans as warranted.
Closure Date:
8 We recommended that the System Director review and address processes that contribute to delays of inpatient discharge.
Closure Date:
9 We recommended that the System Director strengthen nursing service communication processes to ensure consistent inpatient care coverage and nurses' availability for Emergency Department handoff.
Closure Date:
10 We recommended that the System Director evaluate the adequacy of Emergency Department administrative support staffing and take appropriate action.
Closure Date:
11 We recommended that the System Director improve and monitor compliance with response time requirements for after-hour computerized tomography scan services.
Closure Date:
| ||||
| 17-00394-298 | Inspection of the VA Regional Office Louisville, Kentucky | Audit | ||
1 We recommended the Louisville VA Regional Office Director assess the effectiveness of the most recent refresher training for higher level special monthly compensation.
Closure Date:
2 We recommended the Louisville VA Regional Office Director implement a plan to strengthen oversight and assess the accuracy of secondary reviews involving higher-level special monthly compensation and ancillary benefits.
Closure Date:
3 We recommended the Louisville VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.
Closure Date:
4 We recommended the Louisville VA Regional Office Director implement a plan to conduct training that emphasizes date of claim policies and accurate contention classifications, and to monitor the effectiveness of the training.
Closure Date:
5 We recommended the Louisville VA Regional Office Director implement a plan to strengthen oversight for newly hired staff who establish claims.
Closure Date:
| ||||
| 15-02156-346 | Healthcare Inspection–Review of Opioid Prescribing Practices, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director convene an expert panel knowledgeable in the subspecialties of Pain Medicine and Addiction Medicine to review the subject provider’s opioid prescribing practices within the context of the patients whose treatment varied from guidelines as described in this report, ensure that the expert panel expand the review as necessary, and submit a report of findings to the Veterans Integrated Service Network and Facility Directors.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director ensure the monitoring patients on Suboxone.
Closure Date:
3 We recommended that the Veterans Integrated Service Network Director ensure the Pain Committee strengthens processes to improve communication with the facility to ensure information is relayed timely.
Closure Date:
4 We recommended that the Facility Director ensure that providers access the Prescription Drug Monitoring Program database as required by facility policy and monitor compliance.
Closure Date:
5 We recommended that the Facility Director ensure adequate resources, such as additional staff or allotted duty time, are allocated for patient reviews for opioid therapy appropriateness.
Closure Date:
| ||||
| 17-00515-299 | Inspection of the VA Regional Office Phoenix, Arizona | Review | ||
1 We recommended the Phoenix VA Regional Office Director implement a plan to ensure Rating Veterans Service Representatives follow second signature policy requirements for special monthly compensation rating decisions and perform an effective review.
Closure Date:
2 We recommended the Phoenix VA Regional Office Director implement a plan to improve the second signature review process for special monthly compensation rating decisions.
Closure Date:
3 We recommended the Phoenix VA Regional Director implement a plan to prioritize proposed rating reduction cases for completion at the end of the due process time period.
Closure Date:
4 We recommended the Phoenix VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is accurate.
Closure Date:
5 We recommended the Phoenix VA Regional Office Director implement a plan to update the checklist used to evaluate quality at the time of claims establishment.
Closure Date:
6 We recommended the Phoenix VA Regional Office Director provide training to congressional liaisons on special controlled correspondence to ensure all documents are included in the electronic record in accordance with current Veterans Benefits Administration guidance.
Closure Date:
7 We recommended the Phoenix VA Regional Office Director update the office’s local procedures relating to special controlled correspondence in accordance with current Veterans Benefits Administration procedures.
Closure Date:
| ||||
15169