Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-01540-146 | Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri | Hotline Healthcare Inspection | ||
1 The VA St. Louis Health Care System Director conducts a fact-finding investigation asnecessary to determine whether the chief of the Emergency Department’s conduct wasinconsistent with VA policy and federal regulations and takes action as appropriate.
Closure Date:
2 The VA St. Louis Health Care System Director establishes a standardized process for theadministration of the Columbia-Suicide Severity Rating Scale by Emergency Department staff topatients to maintain the integrity of the suicide risk screen.
Closure Date:
3 The VA St. Louis Health Care System Director establishes a formal policy outliningexpectations for the monitoring of patients by Emergency Department nursing staff after triage.
Closure Date:
4 The VA St. Louis Health Care System Director ensures root cause analyses and administrativeinvestigations are conducted efficiently and effectively if chartered for the same event as perVeterans Health Administration policy.
Closure Date:
5 The VA St. Louis Health Care System Director ensures that institutional disclosures arecompleted within the time frame required by the Veterans Health Administration.
Closure Date:
6 The VA St. Louis Health Care System Director ensures compliance with the Veterans HealthAdministration requirement for reporting healthcare professionals to the appropriate statelicensing board when indicated.
Closure Date:
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| 22-00051-136 | Comprehensive Healthcare Inspection of the Phoenix VA Health Care System in Arizona | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for all Level 3 peer reviews.
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3 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews the Protected Peer Review Committee’s summary analysis quarterly.
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4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for professional practice evaluations.
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5 The Executive Director determines the reasons for noncompliance and ensures staff conduct environment of care inspections in patient care areas at the required frequency.
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6 The Executive Director determines the reasons for noncompliance and ensures staff post signage to indicate areas that are subject to video recording.
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| 22-03503-131 | Financial Efficiency Inspection of the VA Philadelphia Healthcare System | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of all VA financial policy requirements in the review and management of inactive open obligations, and deobligate any identified excess funds.
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2 Ensure cardholders comply with VA financial policy record retention requirements
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3 Establish controls to confirm approving officials and purchase cardholders review purchases for VA policy compliance and ensure contracting is used when it is in the best interest of the government.
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4 Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
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5 Ensure the chief supply chain officer establishes local processes and procedures so that all necessary reports are routinely monitored on the Supply Chain Common Operating Picture, the Generic Inventory Package, or other inventory sites or software systems to ensure performance measures are maintained, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
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6 Ensure supply chain managers implement a plan for staff training to increase awareness of internal controls and data reliability issues, such as conversion factor, within the Generic Inventory Package.
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7 Ensure the chief of supply chain services provides quarterly physical inventory memoranda of “A” classified items to Veterans Integrated Service Network personnel, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
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8 Ensure the chief supply chain officer reviews the facility item master file edit access list of all individuals at the VA medical facility who have permissions to enter or modify data within the item master file each calendar year, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
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9 Develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.
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10 Establish measures to improve compliance with the VA directive to avoid end-of-year pharmaceutical purchases.
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11 Develop a plan to align inventory management practices, such as the use of handheld scanners, bar code labeling, and ABC inventory analysis methodology with VHA policy.
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12 Establish processes to ensure compliance with the Veterans Health Administration directive to complete the B09 reconciliation process.
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| 22-00062-139 | Comprehensive Healthcare Inspection of the VA Southern Nevada Healthcare System in North Las Vegas | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with similar training and privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures electrical receptacles and switches in the mental health unit are covered by metal plates, secured by tamper-resistant screws, and receptacles are flush to the wall.
Closure Date:
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| 22-02725-132 | Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director reviews processes in place to ensure proper response to future medical emergencies in outpatient clinics to include staff training, emergency notification systems, and emergency documentation processes.
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2 The VA Southern Nevada Healthcare System Director reviews the process for and compliance with documentation of cardiopulmonary resuscitation in outpatient clinic settings, and takes action as indicated.
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3 The VA Southern Nevada Healthcare System Director works with outpatient clinic leaders to ensure that all deficiencies identified in the after-action plan are completed and that compliance is monitored.
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4 The VA Southern Nevada Healthcare System Director consults with Office of General Counsel’s Regional Counsel to review the incident and determine if an institutional disclosure is warranted and takes action accordingly.
Closure Date:
5 The VA Southern Nevada Healthcare System Director completes an evaluation of staffs’ understanding of advance care planning, advance directives, and life-sustaining treatment decision processes, and takes action to address identified gaps.
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| 22-00044-142 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 17: VA Heart of Texas Health Care Network in Arlington | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials file and makes a recommendation on continuing the appointment process for physicians with a potentially disqualifying licensure action.
Closure Date:
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| 21-02110-138 | Review of Clinical Care Transition from the Department of Defense to the Veterans Health Administration for Service Members with Opioid Use Disorder | National Healthcare Review | ||
1 The Under Secretary for Health directs the Office of Primary Care and Office of Mental Health and Suicide Prevention to identify barriers to provider documentation of opioid use disorder in progress notes and implement solutions addressing these barriers.
Closure Date:
2 The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention determine impediments to maintaining accurate identification of opioid use disorder in electronic health record problem lists and implement policy and training to support accurate use of problem lists.
3 The Under Secretary for Health confirms the Office of Primary Care and Office of Mental Health and Suicide Prevention evaluate barriers affecting provider access and use of Department of Defense treatment records in Joint Longitudinal Viewer and implement solutions.
4 The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention improve continuity of care by confirming providers are educated on the navigation and retrieval of Department of Defense treatment records in Joint Longitudinal Viewer.
5 The Under Secretary for Health requires the Assistant Under Secretary for Health for Clinical Services/Chief Medical Officer to evaluate and update processes for identification of veterans with a history of opioid use disorder for the provision of opioid overdose risk mitigation strategies.
Closure Date:
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| 22-00488-81 | VA Developed Reporting Metrics for Appeals Modernization Act Decision Reviews but Could Be Clearer on Some Veterans’ Wait Times | Review | ||
1 Update the reporting methodology used in public reports to reflect the total time veterans wait for a final claims decision when their higher level reviews require a supplemental claim be established and completed due to an error.
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2 Revise and clearly state the measures used for calculating and reporting the average duration, from the filing of an initial claim until the claim is resolved and claimants no longer take any action under the Appeals Modernization Act claim, and ensure consistency with subsection M of the act.
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| 22-02989-103 | Financial Efficiency Inspection of the VA New York Harbor Healthcare System | Financial Inspection | ||
1 The VA New York Harbor Healthcare System director to ensure that healthcare system finance office staff and initiating services are aware of policy requirements to conduct reviews on all inactive open obligations and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
Closure Date:
2 The VA New York Harbor Healthcare System director to ensure that healthcare system finance office staff and initiating services that healthcare system staff are conducting finance quality assurance reviews of obligations that were inactive for more than 90 days, as required by Veterans Health Administration Directive 1733, “VHA Finance Quality Assurance Reviews.”
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3 The VA New York Harbor Healthcare System director to ensure cardholders comply with record retention, prior approval, and purchase card reconciliation requirements as required by VA Financial Policy, vol. 16, chap. 1B, “Government Purchase Card for Micro-Purchases.”
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4 The VA New York Harbor Healthcare System director to ensure cardholders verify that vendors have removed all state and local sales taxes from orders, if applicable.
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5 The VA New York Harbor Healthcare System director to ensure authorizing officials implement internal controls over government purchase card activities to ensure compliance with the Government Purchase Card Program.
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6 The VA New York Harbor Healthcare System director to establish internal controls to help ensure the healthcare system monitors the Medical/Surgical Prime Vendor formulary for updates, converts supplies to the prime vendor in the item master file, identifies the prime vendor as the mandatory source for these items in the Generic Inventory Package, and properly sets up Medical/Surgical Prime Vendor supply items in VA’s ordering system.
Closure Date:
7 The VA New York Harbor Healthcare System director to develop a plan to improve collaboration with the prime vendor and its on-site representative to ensure adequate stock is available to meet orders, reduce the need for the healthcare system to use nonprime vendors, and communicate the healthcare system’s usage and in-stock timing needs.
Closure Date:
8 The VA New York Harbor Healthcare System director to ensure a qualified Medical/Surgical Prime Vendor contracting officer’s representative is appointed and performs the required delegated duties.
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9 The VA New York Harbor Healthcare System director to establish internal controls to help ensure the healthcare system submits national contract waivers and justifications prior to purchasing available formulary items from nonprime vendor sources.
Closure Date:
10 The VA New York Harbor Healthcare System director to ensure that prime vendor contract performance issues are routinely reported to the Medical Supplies Program Office and Strategic Acquisition Center using established Veterans Health Administration reporting tools.
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11 The VA New York Harbor Healthcare System director to develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.
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12 The VA New York Harbor Healthcare System director to develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration’s recommended level.
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13 The VA New York Harbor Healthcare System director to develop and implement a plan to report the results of facility-based inventory audits of noncontrolled drug line items, and any follow-up actions taken, as required by Veterans Health Administration policy.
Closure Date:
14 The VA New York Harbor Healthcare System director establish processes to ensure compliance with the Veterans Health Administration directive which requires that B09 reconciliations are signed by the lead pharmacy technician and include appropriate supporting documentation.
Closure Date:
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| 22-03483-133 | Inadequate Community Living Center Processes and Training at the West Texas VA Health Care System in Big Spring | Hotline Healthcare Inspection | ||
1 The West Texas VA Health Care System Director ensures that community living center nursing staff are trained on their roles, responsibilities, and necessary actions when responding to a medical emergency.
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2 The West Texas VA Health Care System Director certifies that mock codes are completed within the community living center at regular intervals and include all community living center nursing staff.
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3 The West Texas VA Health Care System Director ensures that documentation requirements are met by community living center clinical staff and monitors compliance.
Closure Date:
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15039