Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-04652-266 | Review of Alleged Shredding of Claims-Related Evidence at VARO Los Angeles, CA | Audit | ||
1 We recommended the VA Regional Office Director implement a plan to ensure the Los Angeles VA Regional Office staff comply with the Veterans Benefits Administration’s policy for handling, processing, and protection of claims-related documents.
Closure Date:
2 We recommended the VA Regional Office Director assess the effectiveness of the training provided to the Los Angeles VA Regional Office staff on Veterans Benefits Administration’s policy for managing veterans’ and other governmental records.
Closure Date:
3 We recommended the VA Regional Office Director provide documentation to VA OIG that proper action has been taken to process the eight cases that had the potential to affect veterans’ benefits.
Closure Date:
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| 16-00011-259 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Hartshorne VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
Closure Date:
2 We recommended that managers ensure that Hartshorne VA Clinic staff participate in emergency management training and exercises.
Closure Date:
3 We recommended that the Facility Director ensures that a policy/procedure is in place for the identification of individuals entering the Hartshorne VA Clinic.
Closure Date:
4 We recommended that the Facility Director ensures that a Workplace Behavioral Risk Assessment is in place for the Hartshorne VA Clinic.
Closure Date:
5 We recommended that the Facility Director ensures examination room doors are equipped with electronic or manual locks at the Hartshorne VA Clinic.
Closure Date:
6 We recommended that the Hartshorne VA Clinic manager ensures that a privacy sign is available for use when a telehealth visit is in progress.
Closure Date:
7 We recommended that the Hartshorne VA Clinic manager provides feminine hygiene disposal bins in women's public restrooms.
Closure Date:
8 We recommended that the Hartshorne VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
Closure Date:
9 We recommended that the Facility Director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
Closure Date:
10 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
11 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Closure Date:
12 We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
Closure Date:
13 We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
Closure Date:
14 We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.
Closure Date:
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| 15-01432-264 | Healthcare Inspection – Restraint Use, Failure To Provide Care, and Communication Concerns, Bay Pines VA Healthcare System, Bay Pines, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that Emergency Department, Computed Tomography Department, Patient Advocate, and 5B inpatient medical unit staff receive patient-centered care training and/or refresher training.
2 We recommended that the Facility Director conduct a review of the patient advocates’ actions as described in this report and take action as appropriate, including providing guidance regarding the processing of patient/family concerns.
3 We recommended that the Facility Director ensure that physician orders are entered into the electronic health record as required when restraints are used.
4 We recommended that the Facility Director ensure that physician discharge notes contain all required elements and documentation adequately reflects the patient’s care and communication with family.
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| 16-00102-253 | Combined Assessment Program Review of the Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma | 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.
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 ventilation
system outlets are clean and monitor compliance.
4 We recommended that the facility monitor temperature in the
compounding buffer areas and that facility managers monitor compliance.
5 We recommended that facility managers ensure employees
perform and document monthly cleaning of ceilings, walls, lights, and storage shelving in all compounding areas and monitor compliance.
6 We recommended that physicians consistently document
discharge progress notes or instructions that include patient diagnoses and that facility managers monitor compliance.
7 We recommended that clinicians provide discharge instructions
to patients and/or caregivers.
8 We recommended that radiologists document the radiation dose
in the Computerized Patient Record System and that facility managers monitor compliance.
Closure Date:
9 We recommended that the Radiation Safety Officer ensure all computed tomography technologists have documented annual radiation safety training.
10 We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
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| 16-00969-257 | Combined Assessment Program Summary Report - Evaluation of Emergency Airway Management 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 facilities’ policies include plans for managing difficult airways.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers provide all required initial training for designated employees who will perform airway management and ensure initial competency assessment includes all required testing and demonstration 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 facility clinical managers include all required elements in airway management competency reassessments 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, require that facility clinical managers ensure competent clinicians provide emergency airway management during all hours of patient care unless the facility is exempt and that facility managers monitor compliance.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers conduct root cause analyses when clinicians without demonstrated airway management competency perform emergency intubations and that facility managers monitor compliance.
Closure Date:
6 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility clinical managers ensure scopes of practice for non-licensed independent practitioners who perform airway management include a statement related to airway management and that facility managers monitor compliance.
Closure Date:
7 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility Chiefs of Staff ensure clinicians complete required training and experience within a short timeframe after recommending airway management privileges and that facility managers monitor compliance.
Closure Date:
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| 15-04987-198 | Inspection of VA Regional Office Montgomery, AL | Review | ||
1 We recommended the Montgomery VA Regional Office Director develop and implement a plan to ensure staff take timely actions on reminder notifications to request medical reexaminations.
Closure Date:
2 We recommended the Montgomery VA Regional Office Director conduct a review of the 15 temporary 100 percent disability evaluations remaining from our inspection universe as of August 11, 2015, and take appropriate actions.
Closure Date:
3 We recommended the Acting Under Secretary for Benefits implement a time frame in which staff are required to schedule medical reexaminations to ensure accurate benefits payments to veterans.
Closure Date:
4 We recommended the Montgomery VA Regional Office Director implement a plan to prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 16-00110-246 | Combined Assessment Program Review of the Cheyenne VA Medical Center, Cheyenne, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
2 We recommended that Physician Utilization Management Advisors 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 medical waste/biohazard containers are properly covered and monitor compliance.
Closure Date:
4 We recommended that the facility develop a policy that addresses temporary bed locations.
Closure Date:
5 We recommended that the facility revise the Radiation Safety Program policy to include a computed tomography quality control program with annual monitoring by a medical physicist and image quality monitoring, protocol monitoring and a method for identifying and reporting excessive doses to the Radiation Safety Officer, a process for managing/reviewing protocols and procedures to follow when revising protocols, and radiologist review of appropriateness of orders and specification of protocol prior to scans.
Closure Date:
6 We recommended that employees consistently use the required advance directive note titles and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility implement a process for responding to referrals from the Veterans Crisis Line and tracking patients who are at high risk for suicide.
Closure Date:
8 We recommended that the facility implement a process to follow up on high-risk patients who missed mental health appointments and that facility managers monitor compliance.
Closure Date:
9 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:
10 We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
Closure Date:
11 We recommended that treatment teams review patients’ high-risk flags at least every 90 days and that facility managers monitor compliance.
Closure Date:
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| 16-00107-256 | Combined Assessment Program Review of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers ensure completion of at least 75 percent of all utilization management reviews and that facility managers monitor compliance.
2 We recommended that facility managers ensure floors in patient care areas are clean and monitor compliance.
3 We recommended that employees promptly remove outdated commercial supplies from patient care areas and that facility managers monitor compliance.
4 We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
5 We recommended that facility managers ensure operating rooms are clean and monitor compliance.
6 We recommended that the facility repair or replace damaged furniture in the operating rooms.
7 We recommended that the facility revise the competency assessment policy for employees who prepare compounded sterile products to include the required intervals for gloved fingertip sampling.
8 We recommended that the facility revise the compounded sterile products safety policy to include verification of all finished compounded sterile products by a pharmacist.
9 We recommended that facility managers ensure employees perform and document cleaning of storage shelving and bins in all compounding areas and monitor compliance.
10 We recommended that clinicians provide discharge instructions to patients and/or caregivers.
11 We recommended that the facility implement a plan for transition to the allowed note titles.
12 We recommended that employees screen inpatients to determine whether they have advance directives and document the screening and that facility managers monitor compliance.
13 We recommended that employees use the required advance directive note titles and that facility managers monitor compliance.
14 We recommended that the facility ensure new clinical employees complete suicide risk management training within 90 days of being hired and that facility managers monitor compliance.
15 We recommended that the facility ensure the mammography services policy includes all required elements.
16 We recommended that the Controlled Substances Coordinator ensure all required non-pharmacy areas with controlled substances are inspected and monitor compliance.
17 We recommended that the facility strengthen processes to ensure weekly inventories of automated dispensing machines are consistently conducted and that facility managers monitor compliance.
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| 16-00016-241 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Hunter Holmes McGuire VA Medical Center, Richmond, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that contracted Environmental Management Service employees at the Fredericksburg VA Clinic receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
Closure Date:
2 We recommended that the clinic manager ensures that Fredericksburg VA Clinic contracted Environmental Management Service employees receive the required hazardous communications training.
Closure Date:
3 We recommended that the clinic manager reviews the Fredericksburg VA Clinic's hazardous materials inventory twice within a 12-month period.
Closure Date:
4 We recommended that the Fredericksburg VA Clinic manager provides feminine hygiene products and disposal bins in women's public restrooms.
Closure Date:
5 We recommended that clinicians document verbal informed consent for Home Telehealth services.
Closure Date:
6 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
7 We recommended that clinicians document monthly monitoring notes for each month of Home Telehealth program participation.
Closure Date:
8 We recommended that the Facility Director ensures that the facility¿s written policy for the communication of laboratory results includes all required elements.
Closure Date:
9 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
10 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Closure Date:
11 We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
Closure Date:
12 We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.
Closure Date:
| ||||
| 15-04695-231 | Combined Assessment Program Review of the Kansas City VA Medical Center, Kansas City, Missouri | 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 the facility replace missing/stained ceiling tiles in patient care areas.
Closure Date:
3 We recommended that facility managers ensure all patient care areas have secure storage for protected health information.
Closure Date:
4 We recommended that the facility assess the possible subfloor penetration and replace missing and broken floor tiles.
Closure Date:
5 We recommended that facility managers ensure employees perform and document daily floor and monthly storage shelving cleaning in all compounding areas and monitor compliance.
Closure Date:
6 We recommended that clinicians validate patient and/or caregiver understanding of the discharge instructions provided.
Closure Date:
7 We recommended that a medical physicist inspect computed tomography scanners that had repairs or modifications that affected dose or image quality before return to clinical service and document the inspection and that facility managers monitor compliance.
Closure Date:
8 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
9 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:
10 We recommended that clinicians include contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
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15168