Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-01991-387 | Audit of VHA's Homeless Providers Grant and Per Diem Case Management Oversight | Audit | ||
1 We recommended the Interim Under Secretary for Health establish a definitive legal position on Grant and Per Diem Program eligibility.
2 We recommended the Interim Under Secretary for Health revise policies, if necessary, when a definitive legal position is provided on Grant and Per Diem Program eligibility.
3 We recommended the Interim Under Secretary for Health implement controls to ensure grant applications comply with the definitive legal position on Grant and Per Diem Program eligibility.
4 We recommended the Interim Under Secretary for Health assess all medication security controls over controlled and non-controlled substances and conduct additional inspections at funded grantee facilities.
5 We recommended the Interim Under Secretary for Health ensure individually locked medications are safely secured in non-portable storage containers.
| ||||
| 15-00601-376 | Combined Assessment Program Review of the North Florida/South GeorgiaVeterans Health System, Gainesville, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate privileges granted to match their skills and training.
Closure Date:
2 We recommended that the facility reduce credentialing and privileging folders to the two-part format.
Closure Date:
3 We recommended that the Operating Room Committee include the Chief of Staff as a member and that committee minutes reflect review of National Surgical Office reports.
Closure Date:
4 We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
Closure Date:
5 We recommended that Infection Control Committee meeting minutes consistently reflect discussion of all identified high-risk areas.
Closure Date:
6 We recommended that facility managers ensure all buildings designated for health care occupancy at the Lake City campus have fire drills conducted once per shift per quarter and monitor compliance.
Closure Date:
7 We recommended that facility managers ensure negative air pressure systems in the Gainesville campus surgical intensive care unit are functional and monitor compliance.
Closure Date:
8 We recommended that facility managers ensure Gainesville campus locked mental health unit stationary panic alarm testing includes documentation of VA Police response time and ensure testing of portable panic alarms and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure designated employees complete competency assessment on the use of emergency evacuation devices and monitor compliance.
Closure Date:
10 We recommended that engineering managers ensure all Gainesville campus construction workers wear VA-issued identification badges and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure that oral syringes are available for liquid medications in all units/areas at the Lake City and Gainesville campuses and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
12 We recommended that employees screen inpatients to determine whether they want to have a discussion about advance directives and document the screening and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
Closure Date:
14 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes evidence of a completed written test and that facility managers monitor compliance.
Closure Date:
15 We recommended that the facility report provider specific emergency airway management data to the Operative and Invasive Procedures Committee.
Closure Date:
| ||||
| 14-04547-401 | Healthcare Inspection – Quality and Coordination of Care Concerns at Two Veterans Integrated Service Network 15 Facilities | Hotline Healthcare Inspection | ||
1 We recommended that the Interim Under Secretary for Health take steps to prevent prescriptions from being dispensed to deceased veterans.
2 We recommended that the Kansas City VA Medical Center Director strengthen processes for interfacility coordination of care and communication and monitor compliance.
3 We recommended that the Kansas City VA Medical Center Director ensure that processes be strengthened so medication reconciliation is consistently completed and monitor compliance.
4 We recommended that the Kansas City VA Medical Center Director conduct peer reviews of this patient’s care, to include the evaluation and treatment of recurrent falls and the coordination of care.
5 We recommended that the Harry S. Truman Memorial Veterans’ Hospital Director strengthen processes for interfacility coordination of care and communication and monitor compliance.
| ||||
| 14-05078-393 | Healthcare Inspection – Credentialing and Privileging Concerns, Wm. Jennings Bryan Dorn VA Medical Center, Columbia, SC | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that provider privileges reflect current practice.
Closure Date:
| ||||
| 15-01721-382 | Combined Assessment Program Summary Report - Evaluation of Selected Requirements in Veterans Health Administration Community Living Centers | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents who may be candidates for restorative nursing services, the interdisciplinary team documents the reason the resident is not receiving the services or other activities to promote functional status.
Closure Date:
2 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents receiving or supposed to receive restorative nursing services, the interdisciplinary team documents goals in their care plans.
Closure Date:
3 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that nursing employees provide and document restorative nursing services in accordance with the care plan, and if they do not provide the services, they document the reason.
Closure Date:
4 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that employees complete required restorative summary notes and that the Associate Chief Nurse or designee monitors compliance.
Closure Date:
5 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that for residents not progressing toward restorative goals, the interdisciplinary team reassesses the resident care plan and/or adjusts goals and interventions as necessary.
Closure Date:
6 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that Physical Medicine and Rehabilitation therapists discharging residents from therapy document hand-off communication with nursing employees to ensure interventions continue or are discontinued, as applicable.
Closure Date:
7 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facility managers provide and document nursing employee training on range of motion and transfers.
Closure Date:
| ||||
| 15-02276-391 | Healthcare Inspection – Evaluation of a Patient’s Care and Disclosure of Protected Information, Atlanta VA Medical Center, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Interim Under Secretary for Health evaluate options that would allow managers to identify individuals who access non-sensitive patient electronic health records.
Closure Date:
2 We recommended that the Facility Director ensure that Mental Health Assessment Team appointments are scheduled within required timeframes, that patients are properly notified of those appointments, and that appropriate follow-up is documented when patients miss Mental Health Assessment Team appointments.
Closure Date:
3 We recommended that the Facility Director ensure that Housing and Urban Development-VA Supportive Housing program contacts or home visits occur as outlined in the patient's treatment plan.
Closure Date:
4 We recommended that the Facility Director ensure that patient record flags identifying patients at risk for suicide are placed promptly and that required high-risk protocols, including weekly contacts, are implemented and documented accordingly.
Closure Date:
| ||||
| 15-01297-368 | Community Based Outpatient Clinics Summary Report ─ Evaluation of Medication Oversight and Education at Community Based Outpatient Clinics and Other Outpatient Clinics | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians perform and document medication reconciliation at each outpatient episode of care when a new medication is prescribed.
Closure Date:
2 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians consistently provide and document patient education for new outpatient medications.
Closure Date:
3 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians consistently assess and document outpatients' understanding of medication education.
Closure Date:
| ||||
| 15-02456-396 | Healthcare Inspection – Care of an Urgent Care Clinic Patient, Tomah VA Medical Center, Tomah, Wisconsin | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health review current acute stroke treatment policies, and assess the use of telehealth evaluation and more aggressive local treatment in patients presenting to rural and/or low complexity VHA facilities with signs and symptoms of an acute stroke.
Closure Date:
2 We recommended that the Under Secretary for Health review processes to improve the ability to identify unauthorized access to VA medical records.
Closure Date:
3 We recommended that the Under Secretary for Health evaluate the complex rules related to reimbursement for a veteran’s emergency care at non-VA facilities, and determine if changes in policy or law would make it more likely that veterans would make decisions on where to seek emergency care based upon medical circumstances, rather than fear of adverse financial impact.
Closure Date:
4 We recommended that the Facility Director ensure that patients and their families are educated about the services the UCC is equipped to provide.
Closure Date:
5 We recommended that the Facility Director ensure that employees who are involved in assessing and treating stroke patients receive the web-based acute ischemic stroke training required by the facility and that facility managers monitor compliance.
Closure Date:
6 We recommended that the Facility Director ensure that transfer agreements are established as required.
Closure Date:
7 We recommended that the Facility Director review and evaluate computerized tomography scanner routine maintenance schedules to determine if routine maintenance can be conducted during periods of traditionally low utilization.
Closure Date:
8 We recommended that the Facility Director ensure Urgent Care Clinic processes are strengthened to reduce door-to-triage timeliness.
Closure Date:
9 We recommended that the Facility Director ensure that appropriate staff receive Emergency Department Integration Software training.
Closure Date:
| ||||
| 14-05158-377 | Healthcare Inspection – Mismanagement of Mental Health Consults and Other Access to Care Concerns, VA Maine Healthcare System, Augusta, ME | Hotline Healthcare Inspection | ||
1 We recommended the Facility Director remove the language in the Computerized Patient Record System outpatient psychological testing consult that may be interpreted as instructing providers not to enter a consult.
Closure Date:
2 We recommended the Facility Director reevaluate and make the appropriate changes to the methods for referring patients for mental health care, including the extent to which the consult package is being used appropriately.
Closure Date:
3 We recommended the Facility Director ensure that mental health consults are reviewed and closed in accordance with Veterans Health Administration policy.
Closure Date:
4 We recommended the Facility Director ensure that Veterans Health Administration appointment scheduling guidance is followed and that schedulers utilize the electronic waiting list and give priority to service connected veterans, as appropriate.
Closure Date:
5 We recommended the Facility Director review all existing mental health wait lists to identify patients who may be at risk because of a delay in the delivery of mental health care and provide the appropriate care.
Closure Date:
6 We recommended the Facility Director expand access to mental health services, particularly required evidence-based psychotherapy and intensive case management services.
Closure Date:
7 We recommended the Facility Director ensure that mental health staff is available in the Emergency Department as required by Veteran Health Administration and local policy to avoid potential delays in admission to the inpatient psychiatry unit.
Closure Date:
8 We recommended the Facility Director review guidance provided to staff about meeting performance measures 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:
| ||||
| 14-00730-206 | Review of Alleged Improper Advances of VHA Appropriated Funds to the U.S. Government Printing Office | Audit | ||
1 We recommended Deputy Assistant Secretary for Acquisition and Logistics take steps to consult with the Office of General Counsel to remedy the inappropriate expenditure of approximately $2.3 million of expired funds, determine whether VA should
de-obligate any outstanding balances, and evaluate the need to return Supply Fund service fees of approximately $5.6 million.
Closure Date:
2 We recommended Deputy Assistant Secretary for Acquisition and Logistics implement a corrective action plan to ensure that fiscal controls are enforced to avoid future misuse of appropriated funds, including inappropriate use of the VA Supply Fund, and the parking of funds.
Closure Date:
3 We recommended the Deputy Assistant Secretary for Finance review the fiscal controls in the Financial Management System to ensure data integrity and an audit trail that reflects the occurrence and source of any accounting record changes.
Closure Date:
4 We recommended the Deputy Under Secretary for Health for Operations and Management confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any, against
Chief Business Office officials for directing the misuse of approximately $43.1 million of fiscal year 2011 appropriated funds.
Closure Date:
5 We recommended the Deputy Assistant Secretary for Acquisition, Logistics, and Construction confer with the Office of Human Resources and the VA Office of General Counsel to determine the appropriate administrative action to take, if any, against Supply Fund management for circumventing controls over the management of funds.
Closure Date:
| ||||
15303