Recommendations
2118
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-00729-23 | Mental Health Inspection of the VA NY Harbor Healthcare System in New York | Mental Health Inspection Program | ||
1 The Associate Chief of Staff, Mental Health ensures compliance with Veterans Health Administration requirements for a full-time local recovery coordinator.
Closure Date:
2 The Associate Chief of Staff, Mental Health ensures the implementation of written processes for staff training, education, and recovery-oriented services.
3 The Facility Director identifies and addresses barriers to communal room access for veterans on the inpatient unit.
4 The Facility Director ensures accurate reporting of inpatient mental health beds and implements processes to monitor.
5 The Facility Director formalizes written processes to monitor and track compliance with state involuntary commitment requirements.
6 The Facility Director ensures staff document veterans’ legal commitment status in the electronic health record and monitors for compliance.
7 The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed medications and monitors for compliance.
8 The Chief of Staff ensures discharge instructions for veterans include appointment locations written in easy-to-understand language.
9 The Chief of Staff ensures discharge instructions for veterans include the purpose for each medication listed and are free of medical abbreviations.
10 The Chief of Staff directs staff to complete and document the Columbia-Suicide Severity Rating Scale within 24 hours before veterans’ discharge and monitors for compliance.
11 The Chief of Staff directs staff to complete suicide prevention safety plans and provide copies of the plans to veterans or caregivers and monitors for compliance.
12 The Chief of Staff directs staff to address ways to make veterans’ environments safer from potentially lethal means, beyond firearms and opioids, in safety plans and monitors for compliance.
13 The Under Secretary for Health identifies barriers to, and ensures documentation of, discussions specific to making the environment safer from identified lethal means in veterans’ safety plans.
14 The Facility Director directs staff to comply with suicide prevention training requirements and monitors for compliance.
15 The Facility Director ensures compliance with Veterans Health Administration requirements for the Interdisciplinary Safety Inspection Team, including recording of meeting minutes, membership, and attendance, and monitors for compliance.
16 The Facility Director implements processes to ensure the Interdisciplinary Safety Inspection Team applies Mental Health Environment of Care Checklist standards on the inpatient mental health unit and monitors for compliance.
17 The Facility Director directs inpatient unit staff and Interdisciplinary Safety Inspection Team members to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.
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| 25-00205-26 | Healthcare Facility Inspection of the VA Gulf Coast Healthcare System in Biloxi, Mississippi | Healthcare Facility Inspection | ||
1 The Associate Medical Center Director ensures Environmental Management Services and nutrition staff maintain clean patient food storage areas.
2 The Associate Medical Center Director ensures staff monitor storage areas and remove expired supplies.
3 The Associate Medical Center Director ensures Environmental Management Services staff make feminine hygiene products available in public women’s and unisex restrooms.
4 The Chief of Staff ensures staff establish written service-level workflows for the communication of test results.
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| 24-03206-21 | Healthcare Facility Inspection of the VA Clarksburg Healthcare System in West Virginia | Healthcare Facility Inspection | ||
1 Executive leaders ensure staff store clean and dirty equipment separately, repair torn furnishings, and keep the environment clean.
2 Executive leaders ensure staff evaluate the cardboard backboards for pest concerns and reduce the risk of infection.
Closure Date:
3 Executive leaders ensure the facility’s policy for test result communication aligns with the VHA directive.
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| 23-02182-185 | Independent Audit Report of Pharma Logistics LLC’s Billing Compliance | Audit | ||
1 Confer with the Office of General Counsel regarding the potential recovery of the $4.4 million in manufacturer credits that were issued by manufacturers and retained by Pharma Logistics before the associated jobs were closed.
2 Contact the Office of General Counsel regarding the potential recovery of unsupported discrepancies between the total credits received and amounts disbursed.
3 Contact the Office of General Counsel regarding the potential recovery of unsupported return credits to manufacturers.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $4,138,382
Closed: $0
Total: $4,138,382
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| 25-00199-19 | Healthcare Facility Inspection of the VA Tampa Healthcare System in Florida | Healthcare Facility Inspection | ||
1 Facility leaders ensure staff have access to sinks or hand hygiene supplies in or near soiled utility rooms that store biohazardous materials.
Closure Date:
2 Facility leaders assess how staff monitor video laryngoscope supplies to ensure they are readily available, and staff remove supplies when they expire.
3 Facility leaders ensure staff develop service-level workflows for the communication of test results per the VHA directive.
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| 24-03420-18 | Healthcare Facility Inspection of the VA Sioux Falls Health Care System in South Dakota | Healthcare Facility Inspection | ||
1 Executive leaders ensure staff post safety risk assessment permits for all construction projects.
2 The Director assigns a member of the executive leadership team as chair of the Construction Safety Committee to oversee safety activities.
Closure Date:
3 Executive leaders ensure staff install privacy curtains in all exam rooms.
4 Executive leaders ensure staff install handrails on both sides of the hallway in the Community Living Center.
5 Executive leaders ensure staff follow the facility’s policy for communication of abnormal test results to patients.
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| 25-00192-15 | Healthcare Facility Inspection of the South Texas Veterans Health Care System in San Antonio | Healthcare Facility Inspection | ||
1 The Associate Director for Operations ensures staff keep patient care areas clean and clean storage areas free of dirty items and equipment.
2 The Chief of Staff ensures the facility has workflows for all services to identify team members’ roles in the test result communication process.
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| 25-00077-215 | Audit of Homeless Screening Clinical Reminder Process | Audit | ||
1 Ensure medical facilities establish and implement clear written Homeless Screening Clinical Reminder policies that define the roles and responsibilities of staff involved in the referral, follow-up, and monitoring processes.
2 Ensure medical facility staff involved in the Homeless Screening Clinical Reminder process are aware of and trained on written local policies and procedures for making referrals, conducting follow-up, and monitoring.
3 Develop and implement a review process to determine whether medical facility staff followed local Homeless Screening Clinical Reminder policies whenever a veteran does not receive a follow-up encounter within 30 days of a positive screening and correct any identified deficiencies.
4 Ensure all medical facilities have a reliable report that accurately lists veterans who screened positive and accepted referrals as well as the status of follow-up actions.
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| 25-01187-244 | Evaluation of Specimen Readings for Accuracy and Quality Assurance in the Laboratory at the John D. Dingell VA Medical Center in Detroit, Michigan | Hotline Healthcare Inspection | ||
1 The VA Detroit Healthcare System Director ensures pathology and laboratory medicine service leaders communicate feedback regarding staff-specific errors to facilitate staff learning and according to Veterans Health Administration high reliability organization guidance.
2 The VA Detroit Healthcare System Director evaluates the quality and patient safety service response to patient safety events, including tracking and monitoring of service level corrective action plans to ensure timely resolution of patient safety events, and takes action as necessary.
3 The VA Detroit Healthcare System Director verifies pathology and laboratory medicine service leaders demonstrate clear communication of the laboratory quality management technologist roles and responsibilities in accordance with Veterans Health Administration requirements.
4 The VA Detroit Healthcare System Director ensures the pathology and laboratory medicine service will sustain oversight of manual complete blood count with differential reads for accuracy via retrospective pathologist secondary reviews.
5 The VA Detroit Healthcare System Director makes certain that pathology and laboratory medicine service leaders track variance reporting and ensure completion of applicable corrective action in accordance with facility policy and Veterans Health Administration requirements.
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| 25-01255-242 | Review of Veterans Health Administration’s National Teleradiology Program | National Healthcare Review | ||
1 The Director, National Teleradiology Program ensures guidance in memoranda of understanding, teleradiology service agreements, and policies related to the entity responsible for the completion of National Teleradiology Program radiologist peer reviews is consistent and aligns with Veterans Health Administration requirements.
2 The Director, National Teleradiology Program reviews the barriers, to include staffing shortages, to achieving turnaround time goals and creates a plan of action to optimize results.
3 The Director, National Teleradiology Program, in cooperation with Veterans Health Administration’s National Radiology Program, explores additional options for the recruitment and retention of National Teleradiology Program radiologists.
4 The Under Secretary for Health, in cooperation with Veterans Health Administration’s National Radiology Program, reviews the tools available for the recruitment and retention of radiologists across the Veterans Health Administration and creates a plan of action to optimize filling vacant positions.
5 The Under Secretary for Health ensures all facilities with an agreement for service by the National Teleradiology Program have a contingency plan.
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15259