Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02139-156 | Healthcare Inspection – Suicide Risk and Alleged Medical Management Issues, Hampton VA Medical Center, Hampton, Virginia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that contracted providers in all patient care areas complete the Veterans Health Administration’s suicide risk management training.
2 We recommended that the Facility Director ensure development of a process to measure the effectiveness of Veterans Health Administration required suicide risk management training for all staff members who have completed it and to provide remedial training when needed.
| ||||
| 15-01809-163 | Combined Assessment Program - Evaluation of Coordination of Care in Veterans Health Administration Facilities | 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 provide and document discharge instructions for all identified needs and that facility managers monitor compliance.
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 reassess patients¿ learning needs prior to providing important instructions, including discharge instructions, and that facility managers monitor compliance.
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 reconcile conflicting needs and instructions before discharging patients and that facility managers monitor compliance.
Closure Date:
4 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that patients receive ordered post-discharge referrals and that facility managers monitor compliance.
Closure Date:
| ||||
| 15-00116-191 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Dayton VA Medical Center, Dayton, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC staff minimize the risk of infection when storing and disposing of medical (infectious waste) at the Lima CBOC.
Closure Date:
2 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispense or administer medications at the Lima CBOC and that compliance is monitored.
Closure Date:
3 We recommended that processes are strengthened at the Lima CBOC to ensure that women veterans can access gender-specific restrooms without entering public areas at the Lima CBOC.
Closure Date:
4 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
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 staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
7 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:
8 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
9 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
| ||||
| 14-02383-175 | Audit of VA's Drug-Free Workplace Program | Audit | ||
1 We recommended the Deputy Assistant Secretary for Human Resources Management ensure that all final selectees for Testing Designated Positions complete pre-employment drug testing prior to appointment.
Closure Date:
2 We recommended the Deputy Assistant Secretary for Human Resources Management collect data that would ensure accountability that all employees selected for random drug testing are tested.
Closure Date:
3 We recommended the Deputy Assistant Secretary for Human Resources Management develop procedures to ensure the Drug Testing coding of employees in Testing Designated Positions is accurate and complete in the Personnel and Accounting Integrated Data system.
Closure Date:
4 We recommended the Deputy Assistant Secretary for Human Resources Management coordinate with the Under Secretary for Health to implement procedures to ensure Custody and Control forms are accurately completed.
Closure Date:
5 We recommended the Deputy Assistant Secretary for Human Resources Management implement processes to adequately monitor local compliance with VA's Drug-Free Workplace Program requirements.
Closure Date:
| ||||
| 14-04623-120 | Inspection of VA Regional Office Manchester, New Hampshire | Review | ||
1 We recommended the Manchester VA Regional Office Director conduct a review of the 111 temporary 100 percent disability evaluations remaining from their inspection universe as of August 21, 2014, and take appropriate action.
Closure Date:
2 We recommended the Manchester VA Regional Office Director develop and implement a plan to ensure staff take timely action on reminder notifications for medical reexaminations.
Closure Date:
3 We recommended the Manchester VA Regional Office Director enforce Veterans Benefits Administration's second-signature review policy for traumatic brain injury rating decisions.
Closure Date:
4 We recommended the Manchester VA Regional Office Director enforce the VARO's second signature review policy for special monthly compensation and ancillary benefits rating decisions.
Closure Date:
| ||||
| 14-04622-150 | Inspection of VA Regional Office Fargo, North Dakota | Review | ||
1 We recommended the Fargo VA Regional Office Director provide training and assess the effectiveness of that training, to ensure staff properly establish permanent disability evaluations when required.
Closure Date:
2 We recommended the Fargo VA Regional Office Director conduct a review of the 40 temporary 100 percent disability evaluations remaining from their universe as of August 21, 2014, and take appropriate action.
Closure Date:
3 We recommended the Fargo VA Regional Office Director implement a plan to ensure staff address all pending issues related to SMC and ancillary benefits.
Closure Date:
| ||||
| 15-00880-157 | Review of Alleged Data Manipulation at VA Regional Office Honolulu, HI | Audit | ||
1 We recommended the Honolulu VA Regional Office Director take immediate action to fully review and correct, as appropriate, all improper actions taken by the supervisor.
Closure Date:
2 We recommended the Honolulu VA Regional Office Director ensure staff receive training on the proper procedures for processing dependency questionnaires.
Closure Date:
3 We recommended the Honolulu VA Regional Office Director confer with Regional Counsel and human resources to determine the appropriate administrative action to take, if any, against this employee.
Closure Date:
| ||||
| 14-00730-170 | Administrative Investigation, Prohibited Personnel Practice and Misuse of VA Time and Resources, Veterans Health Administration, Chief Business Office Purchased Care, Denver, CO | Administrative Investigation | ||
1 We recommend that the Acting Deputy Under Secretary for Health for Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate corrective action to take, if any, concerning the prohibited personnel practice and improper use of a non-competitive hiring authority to reinstate Mr. Sigley.
Closure Date:
2 We recommend that the Acting Principal Deputy Under Secretary for Health (PDUSH) confer with OHR and OGC to determine the appropriate administrative action to take, if any, against (redacted).
Closure Date:
3 We recommend that the PDUSH confer with OHR and OGC to determine the appropriate administrative action to take, if any, against (redacted).
Closure Date:
| ||||
| 15-00794-151 | Healthcare Inspection - Delay of Care, Goshen Community Based Outpatient Clinic, Goshen, Indiana | Hotline Healthcare Inspection | ||
1 We recommended that the VA Northern Indiana Health Care System Director ensure a review of this patient's care is conducted.
Closure Date:
2 We recommended that the VA Northern Indiana Health Care System Director ensure Goshen Community Based Outpatient Clinic patients are aware of the process for contacting a VA Northern Indiana Health Care System Patient Advocate when concerns regarding provider communication or access to medical care arise.
Closure Date:
| ||||
| 14-02437-117 | Healthcare Inspection – Staffing and Quality of Care Issues in the Community Living Center, Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director require that all nursing staff in the Community Living Center receive the required training on the use of the wound vacuum assisted closure device.
Closure Date:
| ||||
15160