Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00603-477 | Combined Assessment Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Surgical Work Group meet monthly.
Closure Date:
2 We recommended that the facility include most outpatient services in the review of electronic health record quality.
Closure Date:
3 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
Closure Date:
4 We recommended that facility managers ensure designated employees receive evacuation device training and monitor compliance.
Closure Date:
5 We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for all users with access to the machines.
Closure Date:
6 We recommended that teleradiology include radiation dose information in computed tomography summary reports and that facility managers monitor compliance.
Closure Date:
7 We recommended that employees screen inpatients to determine whether they have advance directives and document the screening using the appropriate note titles and that facility managers monitor compliance.
Closure Date:
8 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:
9 We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
Closure Date:
10 We recommended that the facility develop and grant a scope of practice that includes emergency airway management for respiratory therapists who have established competency to perform the procedure.
Closure Date:
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| 13-03054-463 | Administrative Investigation, Improper Use of Web-based Collaboration Technology, Office of Information and Technology | Administrative Investigation | ||
1 We recommend that the VA Chief of Staff confer with the Offices OIT, OPIA, and General Counsel (OGC) to ensure that VA Yammer is formally evaluated, approved, and/or disapproved for VA use. If approved, ensure it meets all Federal laws and regulations, as well as VA policy and guidance. If disapproved, ensure that all VA employees cannot access it from VA-issued equipment or VA's network.
Closure Date:
2 We recommend that the VA Chief of Staff confer with the Offices of Human Resources (OHR), Accountability Review (OAR), and OGC to determine the appropriate administrative action to take, if any, against accountable OIT and OPIA officials, as well as other VA and contractor employees involved in this particular matter.
Closure Date:
3 We recommend that the VA Chief of Staff ensure that all VA employees are made fully aware of which Web-based collaboration technologies VA has approved for their use and which are prohibited.
Closure Date:
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| 15-04652-448 | Review of Alleged Shredding of Claims-Related Evidence at the VA Regional Office Los Angeles, California | Audit | ||
1 We recommend 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 recommend 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 recommend 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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| 15-00134-454 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Northport VA Medical Center, Northport, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure a clean and well maintained environment of care at the East Meadow CBOC
Closure Date:
2 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the East Meadow CBOC.
Closure Date:
3 We recommended that employees at the East Meadow CBOC receive the required training on hazardous materials.
Closure Date:
4 We recommended that hand hygiene compliance is monitored at the East Meadow CBOC and reported to the Infection Control Committee.
Closure Date:
5 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
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 the facility director ensures that the facility's written policy for the communication of laboratory results includes all required elements.
Closure Date:
8 We recommended that clinicians consistently notify patients of their laboratory results within 14 days, as required by VHA.
Closure Date:
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| 15-02131-471 | Healthcare Inspection – Unexpected Death of a Patient During Treatment with Multiple Medications, Tomah VA Medical Center, Tomah, WI | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Veterans Integrated Service Network Director review the care of the patient who is the subject of this report and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
Closure Date:
2 We recommended that the Acting Facility Director ensure compliance with VHA Handbook 1004.01, Informed Consent for Clinical Treatments and Procedures as it relates to medication administration.
Closure Date:
3 We recommended that the Acting Facility Director review all elements needed to respond effectively to medical emergencies including staff training, equipment, and other resources at both the unit and the facility level and take any appropriate actions.
Closure Date:
4 We recommended that the Acting Facility Director review and evaluate medications currently available on emergency crash carts, including but not limited to, reversal agents for narcotic and/or benzodiazepine toxicity and make changes as appropriate.
Closure Date:
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| 14-00545-343 | Review of Alleged Mismanagement of VHA's Service-Oriented Architecture Research and Development Pilot Project | Audit | ||
1 We recommended the Under Secretary for Health establish an oversight mechanism to ensure the use of proper appropriations for Veterans Health Administration information technology projects.
Closure Date:
2 We recommended the Under Secretary for Health remedy all Medical Support and Compliance appropriations used to pay for Service-Oriented Architecture Research and Development.
Closure Date:
3 We recommended the Under Secretary for Health confer with VA’s Office of Accountability Review regarding administrative actions against Veterans Health Administration senior officials, beyond those individuals who have left VA employment, who were involved with Service-Oriented Architecture Research and Development funding decisions and ensure that action is taken, if appropriate.
Closure Date:
4 We recommended the Executive in Charge, Office of Information and Technology, obtain Chief Financial Officer certifications from responsible VA Administrations or Staff Offices that proper appropriations will be used before using any non-Information Technology Systems appropriations for any information technology project, including projects managed by the Project Management Accountability System.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $2,600,000
Total: $2,600,000
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| 15-00139-451 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Mann-Grandstaff VA Medical Center, Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 We recommended that panic buttons are tested and that testing is documented at the Wenatchee Community Based Outpatient Clinic.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that the Facility Director identifies a Lead Human Immunodeficiency Virus Clinician to carry out required responsibilities.
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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| 14-04983-412 | Inspection of VA Regional Office Cleveland, Ohio | Review | ||
1 We recommended the Cleveland VA Regional Office Director conduct a review of the 880 temporary 100 percent disability evaluations remaining from their universe as of October 8, 2014, and take appropriate actions.
Closure Date:
2 We recommended the Cleveland VA Regional Office Director provide training on prioritizing temporary 100 percent disability evaluation claims and assess the effectiveness of that training.
Closure Date:
3 We recommended the Cleveland VA Regional Office Director certify that corrective action has been accomplished for the seven cases still requiring action from our September 2012 inspection.
Closure Date:
4 We recommended the Cleveland VA Regional Office Director implement a plan to monitor the effectiveness of training on traumatic brain injury claims.
Closure Date:
5 We recommended the Cleveland VA Regional Office Director implement a plan to ensure staff comply with Veterans Benefits Administration's second-signature requirements for traumatic brain injury claims, including tracking and trending errors in processing to identify local training needs.
Closure Date:
6 We recommended the Cleveland VA Regional Office Director implement a plan to assess the effectiveness of the recent special monthly compensation training and continue to provide refresher training on higher levels of special monthly compensation and ancillary benefits.
Closure Date:
7 We recommended the Cleveland VA Regional Office Director implement a plan to provide refresher training to staff on establishing accurate dates of claim in the Veterans Benefits Administration's electronic systems of record and assess the effectiveness of the training.
Closure Date:
8 We recommended the Cleveland VA Regional Office Director implement a plan to ensure staff establish accurate dates of claim in the Veterans Benefits Administration's electronic systems of record.
Closure Date:
9 We recommended the Cleveland VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Closure Date:
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| 15-01579-457 | Healthcare Inspection – Review of the Operations and Effectiveness of VHA Residential Substance Use Treatment Programs | National Healthcare Review | ||
1 We recommended that Mental Health Services liaison with internal and external entities regarding standardized data collection from screening processes to core outcome measures to improve program monitoring and by which Mental Health Services can develop collaborative treatment initiatives.
Closure Date:
2 We recommended that Mental Health Services ensure system-wide use of the 596 stop code.
Closure Date:
3 We recommended that Mental Health Services review the consistency of current processes and provides specific guidance on reducing inflow of contraband into residential substance use treatment programs.
Closure Date:
4 We recommended that Mental Health Services consider requiring programs to document patients' physical status in addition to presence when completing physical bed checks.
Closure Date:
5 We recommended that Mental Health Services clarify the intent of the requirement for and use of closed circuit television with respect to residential substance use programs.
Closure Date:
6 We recommended that Mental Health Services review and evaluate whether reversal agents such as naloxone are readily available at each residential substance use treatment program.
Closure Date:
7 We recommended that Mental Health Services encourage more widespread incorporation of programming with a specialized focus on mental health comorbidities.
Closure Date:
8 We recommended that Mental Health Services encourage discussion of addiction focused pharmacotherapy with residential substance use treatment program patients.
Closure Date:
9 We recommended that Mental Health Services ensure that active mental health comorbidities are addressed in residential substance use rehabilitation treatment program interdisciplinary treatment plans.
Closure Date:
10 We recommended that Mental Health Services ensure documentation of post-discharge aftercare appointment arrangements for mental health comorbidities.
Closure Date:
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| 14-04530-414 | Healthcare Inspection – Mental Health-Related Deficiencies and Inadequate Leadership Responsiveness, Central Alabama VA Health Care System, Montgomery, Alabama | Hotline Healthcare Inspection | ||
1 We recommended that the Central Alabama VA Health Care System Director ensure adequate mental health staffing in the community based outpatient clinics to provide timely and appropriate patient care.
2 We recommended that the Central Alabama VA Health Care System Director ensure appropriate review and scheduling of patients on the electronic wait list and Recall Reminder lists provided to management.
3 We recommended that the Central Alabama VA Health Care System Director ensure that staff are trained on the proper use and management of the electronic wait list and the Recall Reminder list, that recall reminder letters are sent to patients, and that compliance is monitored.
4 We recommended that the Central Alabama VA Health Care System Director ensure that clinical staff and the Suicide Prevention program staff follow guidelines on the identification, tracking, treatment, and follow-up of patients at high risk for suicide.
5 We recommended that the Central Alabama VA Health Care System Director ensure that Substance Abuse Treatment Program patients have more timely access to residential/domiciliary beds, as needed.
6 We recommended that the Central Alabama VA Health Care System Director ensure that staff receive appropriate training on the policy requirements for managing disruptive behavior.
7 We recommended that the Central Alabama VA Health Care System Director ensure that the Disturbed Behavior Committee complies with policy on completing and documenting incident/threat assessments and initiating Patient Record Flags.
8 We recommended that the Central Alabama VA Health Care System Director ensure that all Disturbed Behavior Committee Alert Notes, both recent and remote, have been reviewed and appropriate actions taken, if indicated.
9 We recommended that the Central Alabama VA Health Care System Director ensure behavioral Patient Record Flags are re-evaluated within established timeframes.
10 We recommended that the Central Alabama VA Health Care System Director evaluate options available to improve the timeliness of Emergency Department clearance and acute mental health unit admission for high risk patients.
11 We recommended that the Central Alabama VA Health Care System Director ensure that mental health providers adequately document their clinical reasoning when their treatment decisions do not comply with VA/DoD guidelines for medication management in Post-Traumatic Stress Disorder and Substance Use Disorder patients.
Closure Date:
12 We recommended that the Central Alabama VA Health Care System Director approve and issue a Mental Health Treatment Coordinator policy and train appropriate staff on same.
13 We recommended that the Central Alabama VA Health Care System Director ensure assignment of Mental Health Treatment Coordinators for all appropriate patients.
Closure Date:
14 We recommended that the Central Alabama VA Health Care System Director monitor to ensure the Dothan Primary Care contractor complies with staffing and care specifications as outlined in the contract.
15 We recommended that the Central Alabama VA Health Care System Director ensure that the Dothan Primary Care contract complies with Veterans Health Administration policy on the treatment of uncomplicated psychiatric disorders.
16 We recommended that the Central Alabama VA Health Care System Director update the Dothan Mental Health Community Based Outpatient Clinics recorded message to instruct callers on what to do for a mental health emergency and how to access the Suicide Prevention/Crisis lines.
17 We recommended that the Central Alabama VA Health Care System Director reinitiate ongoing professional practice evaluation-related mental health chart reviews.
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