Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00156-490 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of San Francisco VA Health Care System, San Francisco, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that hand hygiene compliance is monitored at the San Francisco VA Clinic and reported to the Infection Control Committee.
Closure Date:
2 We recommended that San Francisco VA Clinic staff store medical waste in a secure location.
Closure Date:
3 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:
4 We recommended that clinic staff ensure that patients with excessive persistent alcohol use receive brief treatment within 2 weeks of the screening.
Closure Date:
5 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:
6 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
7 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 13-03922-453 | Audit of Fiduciary Program Controls Addressing Beneficiary Fund Misuse | Audit | ||
1 We recommended the Under Secretary for Benefits revise policy to require timely removal of a fiduciary from all assigned beneficiaries when an individual case of misuse has been determined.
Closure Date:
2 We recommended the Under Secretary for Benefits retroactively establish debts for all fiduciaries who VBA determined misused beneficiary funds during calendar year 2013.
Closure Date:
3 We recommended the Under Secretary for Benefits revise policy to include clear timeliness standards from the time the hubs determine misuse occurred to the time Pension and Fiduciary Service completes the negligence determination.
Closure Date:
4 We recommended the Under Secretary for Benefits ensure the processing of all misuse actions are incorporated into quality reviews of Fiduciary Program operations.
Closure Date:
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| 15-00452-411 | Inspection of VA Regional Office, Winston-Salem, North Carolina | Audit | ||
1 We recommended the Winston-Salem VA Regional Office Director conduct a review of the 597 temporary 100 percent disability evaluations remaining from our universe as of October 8, 2014, and take appropriate actions.
Closure Date:
2 We recommended the Winston-Salem VA Regional Office Director develop and implement a plan to ensure claims processing staff receive additional training on required actions relating to required medical reexaminations.
Closure Date:
3 We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure staff receive refresher training on processing higher-level special monthly compensation claims.
Closure Date:
4 We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure staff timely process claims related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 15-01290-435 | Inspection of VA Regional Office Wichita, Kansas | Audit | ||
1 We recommended the Wichita VA Regional Office Director conduct a review of the 130 temporary 100 percent disability evaluations remaining from our inspection universe as of December 10, 2014, and take appropriate actions.
Closure Date:
2 We recommended the Wichita VA Regional Office Director implement a plan to assess the accuracy of secondary reviews involving higher-level Special Monthly Compensation and ancillary benefits.
Closure Date:
3 We recommended the Wichita VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 15-00604-488 | Combined Assessment Program Review of the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
Closure Date:
2 We recommended that the facility document evacuation sled training in the Talent Management System.
Closure Date:
3 We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
4 We recommended that facility managers ensure post-anesthesia care competency assessment is completed for critical care nurses on the intensive care units.
Closure Date:
5 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes review of clinician-specific data and all required elements and that facility managers monitor compliance.
Closure Date:
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| 13-03917-487 | Audit of VHA’s Efforts To Improve Veterans’ Access to Outpatient Psychiatrists | Audit | ||
1 We recommended the Under Secretary for Health ensure Veteran Integrated Service Networks and facilities incorporate the Office of Mental Health Operations staffing model to determine the appropriate number of psychiatrists needed for outpatient care, and work with those facilities to attain appropriate staffing levels or identify alternative options to meet veteran demand for psychiatrists.
Closure Date:
2 We recommended the Under Secretary for Health develop clinic management business rules to ensure facilities consistently monitor the use of clinical time and number of veterans per psychiatrist, in conjunction with monitoring psychiatrists’ productivity.
Closure Date:
3 We recommended the Under Secretary for Health reassess the appropriateness of the Veterans Health Administration’s productivity target for psychiatrists.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $567,000,000
Total: $567,000,000
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| 15-00001-436 | Inspection of VA Regional Office St. Petersburg, Florida | Audit | ||
1 We recommended the St. Petersburg VA Regional Office Director conduct a review of the 1,717 temporary 100 percent disability evaluations remaining from our inspection universe as of October 8, 2014, and take appropriate action.
Closure Date:
2 We recommended the Under Secretary for Benefits direct Veterans Benefits Administration field offices prioritize processing reminder notifications within 30 days as required.
Closure Date:
3 We recommended the St. Petersburg VA Regional Office Director implement a plan to improve the effectiveness of the second-signature review process for special monthly compensation and ancillary benefits rating decisions
Closure Date:
4 We recommended the St. Petersburg VA Regional Office Director implement a plan to provide training and assess the effectiveness of that training, to ensure staff establish accurate dates of claim in the electronic systems.
Closure Date:
5 We recommended the St. Petersburg VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reductions cases.
Closure Date:
6 We recommended the Under Secretary for Benefits direct Veterans Benefits Administration field offices to prioritize benefits reductions cases in order to minimize overpayments.
Closure Date:
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| 15-00607-483 | Combined Assessment Program Review of the San Francisco VA Health Care System, San Francisco, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers review privilege forms annually and document the review.
Closure Date:
2 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
Closure Date:
3 We recommended that Environment of Care Committee meeting minutes track open items to resolution.
Closure Date:
4 We recommended that Infection Control Committee meeting minutes reflect discussion of all identified high-risk areas and implementation of actions to address those areas.
Closure Date:
5 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
Closure Date:
6 We recommended that facility managers ensure personal protective equipment gowns and eyewear are readily available in all patient care areas and monitor compliance.
Closure Date:
7 We recommended that employees promptly remove outdated commercial supplies from sterile supply rooms and that facility managers monitor compliance.
Closure Date:
8 We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
Closure Date:
9 We recommended that employees secure medication carts when not in use and that facility managers monitor compliance.
Closure Date:
10 We recommended that the facility consistently implement corrective actions for issues identified during monthly community living center medication storage area inspections and that facility managers monitor the changes until issues are fully resolved.
Closure Date:
11 We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
Closure Date:
13 We recommended that facility managers ensure that parenteral syringes are not used to measure oral liquid medications and monitor compliance.
Closure Date:
14 We recommended that computed tomography technologists perform and document quality assurance checks each weekday and that facility managers monitor compliance.
Closure Date:
15 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions using the required advance directive note titles and that facility managers monitor compliance.
Closure Date:
16 We recommended that facility managers ensure that only sharps are disposed of in sharps containers and monitor compliance.
Closure Date:
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| 15-00152-481 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
3 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:
4 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
5 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
6 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:
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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| 15-00597-462 | Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
Closure Date:
2 We recommended that when conversions from observation bed status to acute admissions are 25-30 percent or more, the facility reassesses observation criteria and utilization.
Closure Date:
3 We recommended that the CPR Committee review each code episode.
Closure Date:
4 We recommended that the Surgical Work Group document its review of National Surgical Office reports.
Closure Date:
5 We recommended that the facility keep the recipient list for the automated Critical Incident Tracking Notification e-mail current.
Closure Date:
6 We recommended that the facility review the quality of entries in the electronic health record at least quarterly.
Closure Date:
7 We recommended that the quality control policy for scanning include a complete review of scanned documents to ensure readability and retrievability and that facility managers monitor compliance.
Closure Date:
8 We recommended that the facility revise the observation bed policy to reflect Veterans Health Administration policy and current practice.
Closure Date:
9 We recommended that the Infection Control Committee consistently document analysis of surveillance activities and data.
Closure Date:
10 We recommended that facility managers delegate responsibility for cleaning non-critical equipment and monitor compliance.
Closure Date:
11 We recommended that the facility establish a policy/procedure/guideline for the identification of individuals entering the facility and that facility manager's monitor compliance.
Closure Date:
12 We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
13 We recommended that facility managers ensure that furniture in inpatient mental health patient care areas is compliant with the VA National Center for Patient Safety Mental Health Environment of Care Checklist and monitor compliance.
Closure Date:
14 We recommended that the facility maintain ventilation, temperature, and humidity levels in inpatient care areas according to Joint Commission and Centers for Disease Control and Prevention guidelines and VA policy to provide a safe environment for patients, staff, and visitors and that facility managers monitor compliance.
Closure Date:
15 We recommended that the facility establish a list of resources and assets it may need during an emergency.
Closure Date:
16 We recommended that the facility¿s Emergency Operations Plan include the management of a potential increase in demand for clinical services for patients who are geriatric or disabled or have serious chronic conditions or addictions and the management of mental health services during an emergency.
Closure Date:
17 We recommended that the facility use special medication labeling or institute unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
Closure Date:
18 We recommended that the facility develop and implement a process for managing and labeling high-alert medications and that facility managers monitor compliance.
Closure Date:
19 We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and that facility managers monitor compliance.
Closure Date:
20 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
21 We recommended that the facility develop policies and procedures for managing and reviewing revised computed tomography protocols.
Closure Date:
22 We recommended that a medical physicist review all revised computed tomography protocols and that facility managers monitor compliance.
Closure Date:
23 We recommended that radiologists ensure all computed tomography reports contain the radiation dose and that facility managers monitor compliance.
Closure Date:
24 We recommended that Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees submit timely work orders for items needing repair and that program managers ensure deficiency correction.
Closure Date:
25 We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees perform and document contraband inspections and that program managers monitor compliance.
Closure Date:
26 We recommended that Substance Abuse Residential Rehabilitation Treatment Program managers ensure that the program has written agreements in place acknowledging resident responsibility for medication security.
Closure Date:
27 We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program managers ensure that closed circuit television does not monitor treatment activities.
Closure Date:
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15303