Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-02267-124 | Audit of VHA's Engineering Service Purchase Card Practices at the Ralph H. Johnson VAMC, Charleston, SC | Audit | ||
1 We recommend the Veterans Integrated Service Network 7 Director use data mining and detailed reviews of high risk transactions to review Charleston VA Medical Center Engineering Service’s micro-purchase card transactions made from October 2011 through December 2013 to identify unauthorized commitments, and submit ratification requests for the unauthorized commitments identified by the Office of Inspector General and by Veterans Integrated Service Network 7 to the Veterans Health Administration Head of Contracting Activity.
Closure Date:
2 We recommended the Veterans Integrated Service Network 7 Director use data mining and detailed reviews of high-risk transactions to review Charleston VA Medical Center Engineering Service’s micro-purchase card transactions made from October 2011 through December 2013 for purchases lacking sufficient documentation and take steps to recover identified inappropriate payments.
Closure Date:
3 We recommended the Veterans Integrated Service Network 7 Director develop monitoring mechanisms to ensure Charleston VA Medical Center Engineering Service approving officials consistently use Veterans Health Administration’s required Approving Official Checklist to identify split purchases, purchases that exceed the micro-purchase limit for services, and purchases without sufficient documentation.
Closure Date:
4 We recommended the Veterans Integrated Service Network 7 Director ensure Charleston VA Medical Center Engineering Service’s purchase cardholders and approving officials receive required refresher training every 2 years.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $646,000
Total: $646,000
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| 14-00307-126 | Combined Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the MEC document discussion of PRC quarterly summary reports.
2 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed and that results are consistently reported to the MEC.
3 We recommended that the facility monitor compliance with the new observation bed policy.
4 We recommended that processes be strengthened to ensure that data about observation bed use continues to be gathered.
5 We recommended that processes be strengthened to ensure that continuing stay reviews are performed on at least 75 percent of the patients in acute beds.
6 We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode, that code reviews include screening for clinical issues prior to code that may have contributed to the occurrence of the code, and that code data is collected.
7 We recommended that the Surgical Work Group meet monthly and document its review of required monthly and quarterly performance data elements, including local performance data and National Surgical Office reports.
8 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed at least quarterly.
9 We recommended that the quality control policy for scanning include how a scanned image is annotated to identify that it has been scanned.
10 We recommended that processes be strengthened to ensure that members from Medicine, Surgery, and Anesthesia Services attend Transfusion Process Committee meetings and that the blood/transfusions usage review process includes the results of proficiency testing.
11 We recommended that processes be strengthened to ensure that Infection Control Committee minutes reflect follow-up on actions that were implemented to address identified problems.
12 We recommended that nursing managers continue to monitor the staffing methodology that was implemented in November 2012.
13 We recommended that the facility monitor compliance with the revised pressure ulcer policy as it pertains to prevention for outpatients.
14 We recommended that the newly established Interprofessional Pressure Ulcer Committee meet as required and that the committee provide oversight of the facility’s pressure ulcer prevention program.
15 We recommended that processes be strengthened to ensure that pressure ulcer data is analyzed and that program data is reported to facility executive leadership.
16 We recommended that processes be strengthened to ensure that acute care staff accurately document pressure ulcer location, stage, and risk scale score for all patients with pressure ulcers and that compliance be monitored.
17 We recommended that processes be strengthened to ensure that acute care staff consistently document pressure ulcer stage in initial skin assessments for patients at risk or with pressure ulcers and that compliance be monitored.
18 We recommended that processes be strengthened to ensure that acute care staff develop interprofessional treatment plans for all hospitalized patients identified as being at risk for or with pressure ulcers and that compliance be monitored.
19 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
20 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
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| 13-02926-112 | FY 2013 Review of VA's Compliance With the Improper Payments Elimination and Recovery Act | Audit | ||
1 We recommended the Under Secretary for Health implement the corrective action plan included in the Performance and Accountability Report to reduce improper payments for the State Home Per Diem program.
Closure Date:
2 We recommended the Under Secretary for Health develop achievable reduction targets for the State Home Per Diem and Beneficiary Travel programs.
Closure Date:
3 We recommended the Under Secretary for Benefits ensure thorough procedures for testing sample items used to estimate improper payments for the Compensation and Post 9/11 G.I. Bill programs.
Closure Date:
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| 13-02649-120 | Administrative Investigation, Failure to Comply with Americans with Disabilities Act and VA Policy, Veterans Health Administration | Administrative Investigation | ||
1 We recommend that the Deputy Under Secretary for Health Operations and Management (DUSHOM) confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against the Director.
Closure Date:
2 We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
Closure Date:
3 We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the Director.
Closure Date:
4 We recommend that the DUSHOM confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the LRAC.
Closure Date:
5 We recommend that the DUSHOM confer with OGC and OHRI to determine and execute a plan to provide all VHA employees involved in the RA process, as well as Regional Counsels who provide them advice, the most up to date RA training and guidance, and direct all VHA employees to process RA requests in accordance with applicable Federal laws and regulations and VA policy.
Closure Date:
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| 14-00305-123 | Combined Assessment Program Review of the Southern Arizona VA Health Care System, Tucson, Arizona | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
2 We recommended that the Surgical Work Group meet monthly.
Closure Date:
3 We recommended that processes be strengthened to ensure that all surgical deaths are reviewed.
Closure Date:
4 We recommended that processes be strengthened to ensure that patient care areas in the CLC are clean and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that walls in the CLC are repaired and maintained.
Closure Date:
6 We recommended that processes be strengthened to ensure that all workers who occasionally access the acute MH receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA’s National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that patient learning assessments are conducted and documented and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that clinicians conducting medication education accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that clinicians identify post-discharge needs and include them in discharge planning.
Closure Date:
10 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services within the ordered/expected timeframe.
Closure Date:
11 We recommended that nursing managers monitor the staffing methodology that was implemented in May 2013.
Closure Date:
12 We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
13 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale at discharge and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that acute care staff revise the prevention plans if risk levels change for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
Closure Date:
17 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
18 We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the pressure ulcer risk scale and how to conduct a complete skin assessment and that compliance be monitored.
Closure Date:
19 We recommended that processes be strengthened to ensure that staff document weekly summaries of restorative nursing services in residents’ EHRs.
Closure Date:
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| 14-00234-125 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Lebanon VA Medical Center, Lebanon, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that fire drills are performed every 12 months at the Reading CBOC.
Closure Date:
2 We recommended that CBOC and PCC staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that CBOC and PCC staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
4 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
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| 14-00658-121 | Combined Assessment Program Review of the VA Loma Linda Healthcare System, Loma Linda, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Blood Usage Review Sub-Committee include a clinical representative from Medicine Service as a member.
Closure Date:
2 We recommended that processes be strengthened to ensure that EOC Committee minutes consistently reflect EOC findings from community based outpatient clinic inspections.
Closure Date:
3 We recommended that processes be strengthened to ensure patient care areas are clean and that water leaks and subsequent structural damage are addressed and resolved timely and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that expired medical supplies and medications are removed from patient care areas and that compliance be monitored.
Closure Date:
6 We recommended that all emergency exits on the locked MH unit be alarmed.
Closure Date:
7 We recommended that processes be strengthened to ensure that clinicians provide discharge instructions to patients and/or caregivers and document this in the EHRs and that they validate patients' and/or caregivers' understanding of the discharge instructions they provided and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services.
Closure Date:
9 We recommended that the annual staffing plan reassessment process ensures that unit 2NE's and unit 4SW's unit-based expert panels include all required members and that all members of the unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
10 We recommended that nurse managers reassess the target nursing hours per patient day for unit 2NE to more accurately plan for staffing and evaluate the actual staffing provided.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients at risk for and with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that designated employees receive training on how to administer the pressure ulcer risk scale, how to conduct a complete skin assessment, and how to accurately document findings, and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents' care plans and that compliance be monitored.
Closure Date:
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| 14-00309-118 | Combined Assessment Program Review of the Portland VA Medical Center, Portland, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Operative Care Division Quality and Performance Group meet monthly, include the COS as a member, and document its review of National Surgical Office reports.
Closure Date:
2 We recommended that processes be strengthened to ensure that all surgical deaths are tracked and reviewed by appropriate clinical staff.
Closure Date:
3 We recommended that all emergency exits on the locked MH unit be alarmed.
Closure Date:
4 We recommended that processes be strengthened to ensure that locked MH unit panic alarm testing includes VA Police response time and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that clinicians conducting medication counseling accommodate identified learning barriers and document the accommodations made to address those barriers and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that patients receive ordered aftercare services and/or items within the ordered/expected timeframe.
Closure Date:
8 We recommended that the facility have a Veterans Health Education Coordinator.
Closure Date:
9 We recommended that nursing managers monitor the staffing methodology that was implemented in June 2013.
Closure Date:
10 We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff document stage for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that acute care staff consistently document required pressure ulcer information and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that acute care staff provide and document pressure ulcer education for patients with pressure ulcers and/or their caregivers and that compliance be monitored.
Closure Date:
15 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
16 We recommended that processes be strengthened to ensure that staff document resident progress towards restorative nursing goals and that compliance be monitored.
Closure Date:
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| 13-02053-119 | Healthcare Inspection – Questionable Cardiac Interventions and Poor Management of Cardiovascular Care, Edward Hines, Jr. VA Hospital, Hines, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that cardiologists performing coronary interventions and surgeons performing cardiac surgery adhere to accepted standards of care.
2 We recommended that the Facility Director ensure that adequate equipment is available in the operating room in accordance with VHA policy.
3 We recommended that the Facility Director ensure that processes are strengthened to improve bed utilization.
4 We recommended that the Facility Director ensure that processes are strengthened to ensure contract oversight in accordance with VA requirements.
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| 14-00659-111 | Combined Assessment Program Review of the VA Caribbean Healthcare System, San Juan, Puerto Rico | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the PRC’s membership be revised to ensure that sufficient experienced senior physicians are regular members.
Closure Date:
2 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently reported to the PRC.
Closure Date:
3 We recommended that the Surgical Work Group meet monthly.
Closure Date:
4 We recommended that processes be strengthened to ensure that
all critical incidents are reported through the patient incident reporting process.
Closure Date:
5 We recommended that processes be strengthened to ensure that the Blood Utilization Review Committee members from Surgery and Anesthesia Services consistently attend meetings and that the blood usage review process includes the results of proficiency testing.
Closure Date:
6 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
7 We recommended that processes be strengthened to ensure that EOC and Administrative Executive Board Committee minutes reflect deficiencies identified on the locked MH unit.
Closure Date:
8 We recommended that processes be strengthened to ensure that cabinets containing contrast agents in the radiology area are secured at all times and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that crash cart checks in the radiology area are documented daily and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that all MH unit staff and occasional MH unit workers receive training on how to identify and correct environmental hazards, proper use of the MH EOC Checklist, and VA’s National Center for Patient Safety study of suicide on psychiatric units and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that panic alarm testing documentation includes police response times and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that the medication list provided to the patient/caregiver at discharge is reconciled with the dosage and frequency ordered and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that patients are provided with correct information on discharge instructions.
Closure Date:
14 We recommended that processes be strengthened to ensure that patients’ post-hospitalization outpatient appointments are scheduled within the timeframe requested by the discharging physician.
Closure Date:
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15303