Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00506-535 | Healthcare Inspection – Alleged Access Delays and Surgery Service Concerns, VA Roseburg Healthcare System, Roseburg, Oregon | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Under Secretary for Health perform a quality review of the Chief of Surgery's colonoscopies performed in the prior Veterans Health Administration facility.
Closure Date:
2 We recommended that the Acting Under Secretary for Health revise the Veterans Health Administration Colorectal Cancer Screening directive to include standardized documentation of quality indicators based on professional society guidelines and published literature (including but not limited to photodocumentation of anatomical landmarks establishing cecal intubation and documentation of cecal withdrawal times).
Closure Date:
3 We recommended that the Acting Under Secretary for Health consider adding photodocumentation of cecal intubation and cecal withdrawal time to the standardized criteria for quality colonoscopy for Focused Professional Practice Evaluation/Ongoing Professional Practice Evaluation.
Closure Date:
4 We recommended that the System Director ensure patient notification of diagnostic test results within the required timeframe, particularly for critical results, and that clinicians document notification.
Closure Date:
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| 15-02053-537 | Review of Alleged Improper Pay at VHA's Hudson Valley Health Care System | Audit | ||
1 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System conducts a review of all Federal Wage Service employees’ official duty stations.
Closure Date:
2 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System takes action to correct any inappropriate Federal Wage Service employees’ official duty stations and wage rates.
Closure Date:
3 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System provides training to all management and Human Resources personnel on how to correctly determine an employee’s official duty station.
Closure Date:
4 We recommended the Interim Director of Veterans Integrated Service Network 3 ensure management at the Hudson Valley Health Care System develops procedures to monitor the accuracy of Federal Wage Service employees’ official duty station.
Closure Date:
5 We recommended the Interim Director of Veterans Integrated Service Network 3 conduct a review and consult appropriate VA offices, including the Office of General Counsel, to determine whether administrative action is appropriate for those officials in the Engineering, Environmental Management, and Human Resources Services who did not adequately review or correct employees’ official duty stations in response to the 2014 Office of Human Resources and Administration’s request for verification of all employees’ official duty stations.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $3,555,318
Total: $3,555,318
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| 15-00171-533 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Manchester VA Medical Center, Manchester, New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence
Closure Date:
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| 13-04038-521 | Healthcare Inspection – Alleged Suicides and Inappropriate Changes to Mental Health Treatment Program, Coatesville VA Medical Center, Coatesville, Pennsylvania | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director coordinate with Veterans Health Administration leadership regarding the establishment of a Psychosocial Rehabilitation and Recovery Center.
Closure Date:
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| 15-02745-522 | Review of VBA's Alleged Mismanagement of Unemployability Benefits at VARO Seattle, Washington | Audit | ||
1 We recommended that the Pacific District Director convene an administrative investigation board to determine why VA Regional Office management was unaware that Intake Processing Center staff had stored unprocessed mail for several months without action.
Closure Date:
2 We recommended the Pacific District Director convene an administrative investigation board to determine why staff responsible for managing mail did not seek assistance for processing employment questionnaires for several months.
Closure Date:
3 We recommended the VA Regional Office Director conduct refresher training for staff responsible for processing mail with emphasis on processing employment questionnaires.
Closure Date:
4 We recommended the Under Secretary for Benefits implement a plan that requires audit trails coexist with corrective action plans when areas of mismanagement or data manipulation are identified at VA Regional Offices.
Closure Date:
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| 15-00180-538 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Pacific Islands Health Care System, Honolulu, Hawaii | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers maintain a clean and functioning environment of care at the American Samoa VA Clinic.
Closure Date:
2 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the American Samoa VA Clinic.
Closure Date:
3 We recommended that managers ensure that safety data sheets are readily available to staff at the American Samoa VA Clinic.
Closure Date:
4 We recommended that hand hygiene compliance is monitored at the American Samoa VA Clinic and reported to the Infection Control Committee.
Closure Date:
5 We recommended that staff minimize the risk of infection when storing and disposing of medical (infectious) waste at the American Samoa VA Clinic.
Closure Date:
6 We recommended that written procedures are available and staff are trained to properly disinfect non-critical medical equipment as required at the American Samoa VA Clinic.
Closure Date:
7 We recommended that the information technology server closet at the American Samoa VA Clinic is maintained according to information technology safety and security standards.
Closure Date:
8 We recommended that panic alarms are installed and tested, and testing is documented in all high-risk areas at the American Samoa VA Clinic.
Closure Date:
9 We recommended that the staff at the American Samoa VA Clinic receive regular information/updates on their responsibilities in emergency response operations.
Closure Date:
10 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
11 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
12 We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
13 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
14 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-01590-523 | Review of Alleged Inappropriate Referrals at VHA’s Southern Nevada Healthcare System to a Non-VA Medical Provider | Audit | ||
1 We recommended the Under Secretary for Health ensure that TriWest Healthcare Alliance Corporation meets the terms of the Patient-Centered Community Care contract by referring radiation oncology patients to only American College of Radiology-accredited network practices/facilities.
Closure Date:
2 We recommended the Under Secretary for Health determine whether the Patient-Centered Community Care contract with TriWest Healthcare Alliance Corporation needs to be amended to allow referrals to other than American College of Radiology-accredited network practices/facilities.
Closure Date:
3 We recommended the Under Secretary for Health require the review of medical results for the 15 patients referred to practices/facilities not accredited by the American College of Radiology or American College of Radiation Oncology to ensure they received treatment that met Veterans Health Administration standards of care.
Closure Date:
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| 15-00620-548 | Combined Assessment Program Review of the Manchester VA Medical Center, Manchester, New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 We recommended that when cases receive initial Level 2 or
3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee prior to the final level assignment.
2 We recommended that facility managers review privilege forms annually and document the review.
3 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
4 We recommended that the Code Committee review each code episode.
5 We recommended that the Safe Patient Handling Committee meet monthly and provide oversight of the safe patient handling program.
6 We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, and a complete review of scanned documents to ensure readability and retrievability.
7 We recommended that the facility assign the Suicide Prevention Coordinator full time to suicide prevention activities.
8 We recommended that the facility ensure new employees receive suicide prevention training and that facility managers monitor compliance.
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| 15-00176-541 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Central Arkansas Veterans Healthcare System, Little Rock, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the El Dorado VA Clinic to the parent facility or contracted processing facility.
Closure Date:
2 We recommended that the information technology server closet at the El Dorado VA Clinic is maintained according to information technology safety and security standards.
Closure Date:
3 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
4 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
5 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
6 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
7 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
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:
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| 15-01110-493 | Inspection of VA Regional Office Los Angeles, California | Review | ||
1 We recommended the Los Angeles VA Regional Office Director conduct a review of the 522 temporary 100 percent disability evaluations remaining from our inspection universe as of December 2014, and take appropriate actions.
Closure Date:
2 We recommended the Los Angeles VA Regional Office Director implement a plan to ensure oversight and prioritization of temporary 100 percent disability evaluations.
Closure Date:
3 We recommended the Los Angeles VA Regional Office Director implement a plan to monitor the effectiveness of training on traumatic brain injury claims.
Closure Date:
4 We recommended the Los Angeles VA Regional Office Director implement a plan to ensure staff comply with Veterans Benefits Administration's second-signature requirements for traumatic brain injury claims, and the local procedures for processing traumatic brain injury claims.
Closure Date:
5 We recommended the Los Angeles VA Regional Office Director provide training on higher levels of special monthly compensation for all staff members responsible for evaluating or providing second-signature reviews for these cases.
Closure Date:
6 We recommended the Los Angeles VA Regional Office Director implement a plan to ensure oversight and prioritization of benefit reduction cases.
Closure Date:
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15303