Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00551-128 | Clinical Assessment Program Review of the VA Caribbean Healthcare System, San Juan, Puerto Rico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility managers ensure information technology network room doors at the facility and the St. Croix community based outpatient clinic are secured.
Closure Date:
3 We recommended that the facility repair ceiling leaks and replace stained and/or missing ceiling tiles on the locked mental health unit, in the ambulatory surgery waiting area, at the entrance of the Blind
Closure Date:
4 We recommended that facility managers ensure patient nourishment refrigerators on the medicine/oncology and locked mental health units are clean and do not contain unlabeled food items and monitor compliance.
Closure Date:
5 We recommended that clinicians consistently obtain all required baseline laboratory tests prior to initiating warfarin and that facility managers monitor compliance.
Closure Date:
6 We recommended that clinicians ensure patients newly prescribed warfarin have an international normalized ratio measurement taken within 7 days of warfarin initiation and that facility managers monitor compliance.
Closure Date:
7 We recommended that for patientstransferred out of the facility, providers consistently include documentation of patient or surrogate informed consent.
Closure Date:
8 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
Closure Date:
9 We recommended that for patients transferred out of the facility, sending nurses document nurse-to-nurse communication with the receiving facility.
Closure Date:
10 We recommended that the facility implement an Employee Threat Assessment Team.
Closure Date:
11 We recommended that facility managersensure all employees receive Level I 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.
Closure Date:
12 We recommended that providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens within 30 days of referral.
Closure Date:
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| 16-00550-145 | Clinical Assessment Program Review of the Harry S. Truman Memorial Veterans’ Hospital, Columbia, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
Closure Date:
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.
Closure Date:
3 We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
Closure Date:
4 We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
Closure Date:
5 We recommended that the facility review designated quality assurance data for the anticoagulation management program quarterly and that facility managers monitor compliance.
Closure Date:
6 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and obtain required laboratory tests during warfarin treatment at the frequency required by local policy.
Closure Date:
7 We recommended that the laboratorydirector ensure employees who perform glucose testing at the point of care have annual competencies for glucometers and that facility managers monitor compliance.
Closure Date:
8 We recommended that clinicians take anddocument all actions required by the facility in response to test results and that clinical managers monitor compliance.
Closure Date:
9 We recommended that the facilityimplement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
Closure Date:
10 We recommended that VA Police officer,Patient Safety Manager, and Patient Advocate attendance is consistently documented at Disruptive Behavior Committee meetings.
Closure Date:
11 We recommended that the facility includeand test slow scan/closed circuit televisions, computer-based panic alarm systems, and electronic personal panic alarms in accordance with the local physical security assessment.
Closure Date:
12 We recommended that facility managersensure all employees receive Level 1 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.
Closure Date:
13 We recommended that Cardiopulmonary Resuscitation Committee code reviews include screening for clinical issues prior to code that may have contributed to the occurrence of the code.
Closure Date:
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| 16-00557-134 | Clinical Assessment Program Review of the Boise VA Medical Center, Boise, Idaho | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Environment of Care Committee meeting minutes consistently include discussion and analysis of environment of care rounds deficiencies.
Closure Date:
2 We recommended that the facility revise the Ensuring Correct Surgery and Invasive Procedures policy to include all elements of the timeout checklist required by the Veterans Health Administration.
Closure Date:
3 We recommended that facility managers ensure the Community Nursing Home Oversight Committee meets at least quarterly and includes representation by all required disciplines.
Closure Date:
4 We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews including the analysis of the latest state survey and monitor compliance.
Closure Date:
5 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
Closure Date:
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| 16-03805-20 | Combined Assessment Program Summary Report – Evaluation of Inpatient Flow in Veterans Health Administration Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities revise discharge policies to include encouraging physicians to schedule discharges early in the day.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities develop or revise policies addressing overflow patients in temporary bed locations and include priority placement for inpatient beds given to patients in temporary bed locations, upholding standard of care while patients are in temporary bed locations, medication administration, and meal provision.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when resident physicians complete discharge notes or instructions, supervising physicians co-sign the residents’ notes.
Closure Date:
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| 16-02618-424 | Audit of Veteran Wait Time Data, Choice Access, and Consult Management in VISN 6 | Audit | ||
1 We recommended the Under Secretary for Health establish a method to monitor and ensure Veterans Integrated Service Network compliance with scheduling requirements.
Closure Date:
2 We recommended the Director of Veterans Integrated Service Network 6 ensure that staff at all VA medical facilities use the referring provider’s clinically indicated date, when available, or documented veteran’s preferred appointment date, when scheduling new patient appointments.
Closure Date:
3 We recommended the Director of Veterans Integrated Service Network 6 ensure VA medical facilities conduct required scheduler audits and take corrective actions as needed based on audit results.
Closure Date:
4 We recommended the Under Secretary for Health implement monitoring controls to ensure the third-party administrators return authorizations after 2 business days for urgent care and 5 business days for routine care if an appointment had not been scheduled.
Closure Date:
5 We recommended the Director of Veterans Integrated Service Network 6 ensure Non-VACare Coordination staffing is sufficient to timely administer the requirements of the Choice Program.
Closure Date:
6 We recommended the Under Secretary for Health implement controls to ensure the third party administrators create an appointment for the veteran within 5 business days of receiving an authorization.
Closure Date:
7 We recommended the Under Secretary for Health to ensure all data required to manage the third party administrator contracts provided by the VA and the third party administrators is complete, accurate, and timely.
Closure Date:
8 We recommended the Director of Veterans Integrated Service Network 6 ensure services monitor and timely address consults pending greater than 7 days.
Closure Date:
9 We recommended the Director of Veterans Integrated Service Network 6 identify and implement best practices to timely schedule appointments for consults upon receipt and review by the receiving specialty care clinicians.
Closure Date:
10 We recommended the Director of Veterans Integrated Service Network 6 establish a mechanism to routinely audit closed consults to ensure they are in accordance with Veterans Health Administration consult business rules, and take corrective actions as needed based on audit results.
Closure Date:
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| 15-04925-469 | Evaluation of Human Immunodeficiency Virus Screening in Veterans Health Administration Outpatient Clinics | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinical staff offer HIV screening as part of routine medical care and that managers monitor compliance.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians document informed consent for HIV testing and that managers monitor for compliance.
VA Office
Closure Date:
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| 16-00574-151 | Clinical Assessment Program Review of the Overton Brooks VA Medical Center, Shreveport, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
2 We recommended that Environment of Care Committee meeting minutes consistently document corrective actions taken to address rounds deficiencies and consistently track actions taken in response to identified deficiencies to closure.
Closure Date:
3 We recommended that facility managers ensure ventilation grills and floors in patient care areas are clean and monitor compliance.
Closure Date:
4 We recommended that the facility repair rusted equipment in patient care areas or remove it from service.
Closure Date:
5 We recommended that facility managers ensure sinks in patient nourishment kitchens are clean and monitor compliance.
Closure Date:
6 We recommended that the hemodialysis unit manager ensure sinks and floors are clean and monitor compliance.
Closure Date:
7 We recommended that the hemodialysis unit manager ensure clean and dirty items are stored separately and monitor compliance.
Closure Date:
8 We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
Closure Date:
9 We recommended that clinicians consistently provide transition follow-up to inpatients with newly prescribed anticoagulant medications in accordance with local policy and that facility managers monitor compliance.
Closure Date:
10 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and obtain required laboratory tests during warfarin treatment at the frequency required by local policy.
Closure Date:
11 We recommended that the facility collect and report data on patient transfers out of the facility as required by local policy.
Closure Date:
12 We recommended that facility managers ensure transfer notes are written by a staff/attending physician or are written by an accceptable designee and contain a staff/attending physician countersignature.
Closure Date:
13 We recommended that providers include the evaluation of previous adverse events with anesthesia in the history and physical and pre-sedation assessment and that facility managers monitor compliance.
Closure Date:
14 We recommended that facility managers complete exclusion review documentation when community nursing home annual reviews note four or more exclusionary criteria.
Closure Date:
15 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
Closure Date:
16 We recommended that the facility implement an Employee Threat Assessment Team and that the VA Police Officer and Risk Manager consistently attend Disruptive Behavior Committee meetings.
Closure Date:
17 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to appeal Patient Record Flag placement.
Closure Date:
18 We recommended that facility managers ensure appropriate individuals conduct debriefings after incidents of disruptive or violent behavior and monitor compliance.
Closure Date:
19 We recommended that facility managers ensure all employees receive Level 1 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.
Closure Date:
20 We recommended that community based outpatient clinic/primary care clinic employees consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
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| 14-00750-143 | Healthcare Inspection – Documentation of Patient Enrollment Concerns in Home Telehealth John D. Dingell VA Medical Center Detroit, Michigan | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that home telehealth staff be retrained and follow the Veterans Health Administration home telehealth process of care and documentation requirements.
Closure Date:
2 We recommended that the Facility Director ensure that documentation accurately reflects patients’ home telehealth enrollment status as described in this report.
Closure Date:
3 We recommended that the Facility Director review the circumstances surrounding the entry of Home Telehealth Program monthly monitor notes in electronic health records of patients discussed in this report with the Office of Human Resources and the Office of General Counsel and take appropriate action as necessary.
Closure Date:
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| 15-01436-456 | Audit of VBA’s Automated Burial Payments | Audit | ||
1 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, review the improper payments identified in this report and take appropriate corrective actions when warranted.
Closure Date:
2 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, strengthen controls to ensure intended recipients meet entitlement requirements before authorizing automated burial payments.
3 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with the requirement under the United States Code of Federal Regulations that proof of death be submitted prior to the release of automated burial payments.
Closure Date:
4 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with United States Code of Federal Regulations related to automated burial payments and recipients’ entitlement requirements prior to authorizing payments.
Closure Date:
5 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, ensure quality assurance reviews determine whether staff inappropriately discontinued veterans’ disability benefits and assess whether spouses met entitlement requirements to receive automated burial payments.
Closure Date:
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| 15-01900-142 | Healthcare Inspection – Echocardiography Scheduling and Quality of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that routine, outpatient echocardiography studies are scheduled in accordance with Veterans Health Administration policy.
Closure Date:
2 We recommended that the Facility Director confer with the Office of Chief Counsel (formerly known as Regional Counsel) for possible disclosure to the patient with delayed echocardiography described in this report and take appropriate action, if any.
Closure Date:
3 We recommended that the Facility Director ensure that echocardiography technicians are offered opportunities for re-training and continuing education to improve the quality of the echocardiography image acquisition.
Closure Date:
4 We recommended that the Facility Director ensure that cardiology managers establish performance improvement activities for the echocardiography technicians in accordance with facility policy.
Closure Date:
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15168