Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00112-267 | Combined Assessment Program Review of the James H. Quillen VA Medical Center, Mountain Home, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Suicide Prevention Coordinator consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
2 We recommended that Domiciliary Care for Homeless Veterans Program employees consistently perform and document weekly inspections of a minimum of 10 percent of resident rooms for contraband and that program managers monitor compliance.
3 We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently perform and document daily resident room inspections for unsecured medications and that program managers monitor compliance.
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| 16-00693-269 | Combined Assessment Program Summary Report – Evaluation of Safe Medication Storage Practices in Veterans Health Administration Facilities | 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 facilities’ policies include automated dispensing machine user training and competency assessment requirements and that facility 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 employees perform and document monthly inspections of all medication storage areas and that facility managers monitor compliance.
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 employees identify deficiencies during medication storage area inspections, they document corrective actions and that facility managers monitor compliance.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities have oral syringes available for medication administration and clearly label and store them separately from parenteral syringes and that facility managers monitor compliance.
Closure Date:
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| 16-00017-245 | Review of Community Based Outpatient Clinic and Other Outpatient Clinics of Tuscaloosa VA Medical Center, Tuscaloosa, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers monitor hand hygiene compliance at the Selma VA Clinic.
Closure Date:
2 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
3 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
Closure Date:
4 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Closure Date:
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| 15-02384-212 | Review of VBA’s Alleged Inappropriate Prioritization of Appeals at VARO Roanoke, VA | Audit | ||
1 We recommended that the Roanoke VA Regional Office Director ensure that leadership and appeals staff follow the workload management plan to prioritize work based on the appeals pending the longest.
Closure Date:
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| 16-00115-263 | Combined Assessment Program Review of the Carl Vinson VA Medical Center, Dublin, Georgia | 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 Peer Review Committee monthly meetings are documented.
Closure Date:
3 We recommended that Environment of Care Committee meeting minutes reflect sufficient discussion of environment of care rounds deficiencies, corrective actions taken to address the deficiencies, and tracking of actions to closure for the facility and the community based outpatient clinics.
Closure Date:
4 We recommended that facility managers ensure operating room housekeepers complete initial training on cleaning and disinfection procedures.
Closure Date:
5 We recommended that the facility develop a policy that addresses temporary bed locations.
Closure Date:
6 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
8 We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently identify and document deficiencies concerning resident privacy, submit work orders for items needing repair, and document corrective actions taken for identified deficiencies and that program managers monitor compliance.
Closure Date:
9 We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently perform and document weekly inspections of a minimum of 10 percent of resident rooms for contraband, 2-hour rounds of all public spaces, and daily resident room inspections for unsecured medications and that program managers monitor compliance.
Closure Date:
10 We recommended that the unit 10-B and unit 8-B main points of entry have keyless entry systems.
Closure Date:
11 We recommended that facility managers ensure that the closed circuit television system on unit 8-B have recording capabilities and that unit 10-B have signage alerting veterans and visitors of closed circuit television recording.
Closure Date:
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| 16-00012-251 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Charlie Norwood VA Medical Center, Augusta, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Statesboro VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
Closure Date:
2 We recommended that managers ensure that Statesboro VA Clinic staff participate in emergency management training and exercises.
Closure Date:
3 We recommended that the clinic manager ensures that Statesboro VA Clinic employees receive the required hazardous communications training.
Closure Date:
4 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
5 We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
Closure Date:
6 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
Closure Date:
7 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by local policy.
Closure Date:
8 We recommended that providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens.
Closure Date:
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| 16-00023-252 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Fargo VA Health Care System, Fargo, North Dakota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinicians document assessments and treatment plans for Home Telehealth patients.
2 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
3 We recommended that the Facility Director ensure that the facility’s written policy for the communication of laboratory results includes all required elements.
4 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe required by VHA.
5 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Closure Date:
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| 16-00019-249 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Cheyenne VA Medical Center, Cheyenne, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the clinic manager reviews the Greeley VA Clinic’s hazardous materials inventory twice within a 12-month period.
Closure Date:
2 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
3 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
4 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Closure Date:
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| 16-00013-242 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Kansas City VA Medical Center, Kansas City, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director ensures that signs identify the location of fire extinguishers that are in large rooms or are obscured from view at the Cameron VA Clinic.
Closure Date:
2 We recommended that the clinic manager reviews the Cameron VA Clinic's hazardous materials inventory twice within a 12-month period.
Closure Date:
3 We recommended that the Cameron VA Clinic manager ensures that a privacy sign is available for use when a telehealth visit is in progress.
Closure Date:
4 We recommended that clinic staff protect patient-identifiable information on laboratory specimens during transport.
Closure Date:
5 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
6 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
Closure Date:
7 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-04652-146 | Review of Claims-Related Documents Pending Destruction at VA Regional Offices | Audit | ||
1 We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to ensure documents printed from Veterans Benefits Management System are clearly identified.
Closure Date:
2 We recommended the Acting Under Secretary for Benefits revise Veterans Benefits Administration’s Policy on Management of Veterans’ and Other Governmental Paper Records to include detailed, standardized procedures for the collection and review of material by records management staff at VA Regional Offices.
Closure Date:
3 We recommended the Acting Under Secretary for Benefits implement a plan to ensure all claims-related documents receive the mandated levels of review to comply with Veterans Benefits Administration’s policy.
Closure Date:
4 We recommended the Acting Under Secretary for Benefits implement a plan that requires supervisors to conduct periodic reviews of employees’ red boxes and track all shredding policy violations they identify.
Closure Date:
5 We recommended the Acting Under Secretary for Benefits implement a plan to ensure records management staff comply with Veterans Benefits Administration’s policy to track all shredding violations they identify.
Closure Date:
6 We recommended the Acting Under Secretary for Benefits implement a plan to ensure management and staff receive refresher training on the proper handling of both claims-related and non-claims-related documents.
Closure Date:
7 We recommended the Acting Under Secretary for Benefits develop specific procedures regarding the maintenance and disposition of congressional correspondence.
Closure Date:
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15168