Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-01080-208 | Review of Alleged Overpayments for Non-VA Care Made by Florida VA Facilities | Audit | ||
1 We recommended the Under Secretary for Health develop and implement a plan to ensure all non-VA physician-administered drugs (other than orally administered) are paid in accordance with the Code of Federal Regulations.
Closure Date:
2 We recommended the Under Secretary for Health develop a plan for uploading Medicare rates into the Fee Basis Claims System to enable the proper payment of physician-administered drug claims.
Closure Date:
3 We recommended the Under Secretary for Health issue bills of collection, as necessary and in accordance with VA policy, to recover physician-administered drug overpayments made by Florida VA facilities.
Closure Date:
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| 16-01077-255 | Opioid Management Practice Concerns, John J. Pershing VA Medical Center Popular Bluff, Missouri | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director develop processes to ensure that the relevant providers complete timely patient evaluations for continued long-term opioid therapy for pain based on clinically significant changes or findings to a patient’s health status.
Closure Date:
2 We recommended that the Facility Director ensure that reviews of the cases of the identified patients with clinically significant changes are completed and take action as appropriate.
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3 We recommended that the Facility Director ensure that the relevant providers receive education on the concurrent prescribing of dual short acting opioids and tapering of opioids.
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4 We recommended that the Facility Director ensure that the relevant providers review Veterans Health Administration recommendations regarding the use of opioid risk stratification tools, such as the Opioid Risk Tool, to identify high-risk patients for longterm opioid therapy for pain.
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5 We recommended that the Facility Director ensure that the relevant providers order urine drug screening frequency based on risk assessment and complete urine drug screening at least annually.
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6 We recommended that the Facility Director ensure that the relevant providers consistently use urine drug screening confirmatory testing.
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7 We recommended that the Facility Director develop processes that minimize the potential for urine drug screening tampering.
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8 We recommended that the Facility Director ensure that the relevant providers consistently complete the informed consent process prior to initiating long-term opioid therapy for pain as specified by Veterans Health Administration policy.
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| 16-00581-239 | Clinical Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance
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2 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
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3 We recommended that facility managers ensure floors in patient care areas are clean and monitor compliance.
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4 We recommended that facility managers ensure sharps containers stored for pick-up are secured and monitor compliance.
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5 We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
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6 We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
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7 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
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8 We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history, observations, signs, symptoms, and preliminary diagnoses and that facility managers monitor compliance.
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9 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
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10 We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
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11 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement and ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
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12 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
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| 16-00327-209 | Review of Alleged Mismanagement of VA's Human Resources and Administration Contract Funds | Audit | ||
1 We recommended the Acting Assistant Secretary for Human Resources and Administration assign responsibility to an office to assess hosting solution options for the Dashboard Tool.
Closure Date:
2 We recommended the Acting Assistant Secretary for Human Resources and Administration evaluate funding a hosting solution needed to test and use its estimated $3.7 million Dashboard Tool investment.
Closure Date:
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| 15-01043-247 | Healthcare Inspection – Alleged Unsafe Blood Transfusion Practices, Battle Creek VA Medical Center, Battle Creek, Michigan | Hotline Healthcare Inspection | ||
1 We recommended that the Battle Creek VA Medical Center Director ensure that Battle Creek VA Medical Center managers update the blood transfusion policy to align with AABB blood transfusion guidelines.
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2 We recommended that the Battle Creek VA Medical Center Director ensure that providers follow Battle Creek VA Medical Center policy and report all transfusion adverse reactions to the Blood Usage Review Committee for review.
Closure Date:
3 We recommended that the Battle Creek VA Medical Center Director ensure that the Transfusion Officer who is appointed to the Blood Usage Review Committee has no conflict of interest between committee and professional responsibilities.
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4 We recommended that the Battle Creek VA Medical Center Director ensure that for level 2 and level 3 peer reviews, the Peer Review Committee provide recommendations to supervisors of non-punitive and non-disciplinary actions, that supervisors discuss and follow up with providers, and that Peer Review Committee minutes include documentation of actions and of supervisory follow-up as required by the Veterans Health Administration.
VA
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| 15-05235-200 | Review of Alleged Removal of Workload Controls at the VARO in San Juan, PR | Audit | ||
1 We recommended the San Juan VA Regional Office Director develop and implement a plan to review the 722 End Product 930s that staff removed from its inventory in August and September 2015.
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2 We recommended the San Juan VA Regional Office Director monitor the effectiveness of current plans to manage the End Product 930 workload.
Closure Date:
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| 15-01669-246 | Healthcare Inspection—Patient Deaths, Opioid Prescribing Practices, and Consult Management, VA Greater Los Angeles Healthcare System, | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure staff conduct a review of canceled or discontinued cardiology consults to determine if patients suffered harm as a result of inappropriate consult closure and confer with the Office of Chief Counsel regarding disclosure as necessary.
2 We recommended that the System Director ensure system staff comply with current Veterans Health Administration policies regarding consult management.
Closure Date:
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| 15-01301-242 | Healthcare Inspection – Delays in the Evaluation and Care of a Patient with Lung Cancer, VA Southern Nevada Health Care System, Las Vegas, NV | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that providers address and communicate test results to patients within the timeframe required by the Veterans Health Administration.
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2 We recommended that the System Director ensure that providers timely follow up on non-VA providers’ recommendations.
Closure Date:
3 We recommended that the System Director ensure the Non-VA Medical Care Coordination requirement for patients to be seen by system physicians first for services offered at the system before a Non-VA Medical Care Coordination request is authorized does not delay care.
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4 We recommended that the System Director ensure Non-VA Medical Care Coordination staff process requests according to the urgency noted by the requesting provider.
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5 We recommended that the System Director ensure Emergency Department providers follow Non-VA Medical Care Coordination consult request processes.
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6 We recommended that the System Director ensure that Non-VA Medical Care Coordination staff are knowledgeable of specific services that are authorized when Non-VA Medical Care Consults are approved.
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7 We recommended that the System Director review existing practices for filling nonformulary/restricted medications to ensure that medications are ordered, reviewed, and processed timely.
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8 We recommended that the System Director evaluate patient experiences regarding contracted companies’ processes for delivery of medications and take appropriate corrective actions if needed.
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9 We recommended that the System Director ensure the peer review process is conducted according to current Veterans Health Administration guidance.
Closure Date:
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| 16-03302-252 | Healthcare Inspection – Nutrition and Food Service Environment of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director complete an analysis of the basement and sub-basement structures to determine if adequate measures are in place to prevent water infiltration.
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2 We recommended that the Facility Director ensure that Nutrition and Food Service kitchen staffing is sufficient to perform all required duties including cleaning and sanitation.
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3 We recommended that the Facility Director complete an analysis of the feasibility of relocating the main kitchen to an area that limits the environmental conditions for pests.
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| 16-03808-215 | Evaluation of Suicide Prevention Programs in Veterans Health Administration Facilities | National Healthcare Review | ||
1 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Suicide Prevention Coordinators provide at least five outreach activities per month and that facility managers monitor compliance.
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2 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete Suicide Prevention Safety Plans for all high-risk patients, include in the plans the contact numbers of family or friends for support, and give the patient and/or caregiver a copy of the plan, and that facility managers monitor compliance.
Closure Date:
3 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians, in consultation with Suicide Prevention Coordinators, identify inpatients as at high risk for suicide, they place Patient Record Flags in the patients' electronic health records and notify the Suicide Prevention Coordinator of each patient's admission, and that facility managers monitor compliance.
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4 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that a Suicide Prevention Coordinator or mental health provider evaluates inpatients identified as at high risk for suicide at least four times during the first 30 days after discharge, and that facility managers monitor compliance.
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5 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians identify outpatients as at high risk for suicide, they review the Patient Record Flags every 90 days and document the review and their justification for continuing or discontinuing the Patient Record Flags, and that facility managers monitor compliance.
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6 We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete suicide risk management training within 90 days of hire and that facility managers monitor compliance.
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15168