Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00514-108 | Failure of Leaders to Respond to Reports of Sexual Harassment at the VA Black Hills Health Care System in Fort Meade and Hot Springs, South Dakota | Hotline Healthcare Inspection | ||
1 The VA Black Hills Health Care System Director reviews the sexual harassment policy to ensure that leaders and supervisors can identify, thoroughly investigate, and respond to sexual harassment allegations.
Closure Date:
2 The VA Black Hills Health Care System Director reviews the actions of the Compensated Work Therapy and Transitional Residence program manager related to the identified patient’s case and takes action as needed.
Closure Date:
3 The VA Black Hills Health Care System Director ensures that facility policy addresses the safety and rights of patients who are both VA employees and participants in the Transitional Residence program.
Closure Date:
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| 22-00540-107 | Issues Related to an Administrative Investigation Board at the VA Black Hills Health Care System in Fort Meade and Hot Springs, South Dakota | Hotline Healthcare Inspection | ||
1 The VA Black Hills Health Care System Director continues to monitor and track the identified action plan through to completion.
Closure Date:
2 The VA Black Hills Health Care System Director reviews the evidence and independently determines if the state licensing board should be notified.
Closure Date:
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| 22-00047-106 | Comprehensive Healthcare Inspection of the VA Long Beach Healthcare System in California | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance using objective criteria accepted by the practitioner.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Medical Executive Council reviews and evaluates licensed independent practitioners’ reprivileging requests and documents the review in the meeting minutes.
Closure Date:
3 The Deputy Director evaluates and determines any additional reasons for noncompliance and ensures managers keep furnishings and equipment safe and in good repair.
Closure Date:
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| 21-02805-102 | Review of Access to Telehealth and Provider Experience in VHA Prior to and During the COVID-19 Pandemic | National Healthcare Review | ||
1 The Under Secretary for Health evaluates provider knowledge and utilization of VA Video Connect technology, including resources such as the Digital Divide Consult, Connected Devices Support Program, and VVC Now and takes action as indicated.
Closure Date:
2 The Under Secretary for Health evaluates availability of clinical and administrative support to providers initiating and completing VA Video Connect encounters and clarifies expectations and requirements to ensure access to virtual care emulates in-person encounters.
Closure Date:
3 The Under Secretary for Health ensures education of providers and support staff regarding VA Video Connect scheduling processes.
Closure Date:
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| 22-02067-82 | The Medical Disability Examination Office Needs to Better Monitor Mileage Requirements for Contract Exams | Review | ||
1 Implement a process to monitor and demonstrate progress to assess vendors’ compliance with contractual mileage and travel reimbursement requirements.
Closure Date:
2 Collaborate with vendors to ensure portals include proper documentation of express consent.
Closure Date:
3 Collaborate with vendors to ensure mileage reimbursement information is available in vendor portals.
Closure Date:
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| 21-03313-96 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 9: VA MidSouth Healthcare Network in Nashville, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 The Network Director evaluates and determines additional reasons for noncompliance and submits a Comprehensive Environment of Care compliance report to the Environment of Care Committee annually.
Closure Date:
2 The Network Director evaluates and determines additional reasons for noncompliance and makes certain the Environment of Care Committee reviews Comprehensive Environment of Care Compliance and Assessment Tool data at least quarterly.
Closure Date:
3 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Emergency Management Committee conducts an annual review of the Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement, and documents it in writing.
Closure Date:
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| 22-02604-74 | Audie L. Murphy Memorial Veterans’ Hospital Missed Opportunities to Distribute Excess Ventilators during the COVID-19 Pandemic | Review | ||
1 Document a methodology for determining the number of ventilators required by the Audie L. Murphy Memorial Veterans’ Hospital to fulfill its mission and provide care during routine and emergency operations.
Closure Date:
2 Determine whether the remaining ventilators are required to support the hospital’s mission. If excess ventilators are identified, perform procedures to turn them in for reassignment, reutilization, or disposal in accordance with VA Handbook 7002.
Closure Date:
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| 21-03133-48 | Office of Emergency Management Has Not Deployed a Functional Last-Resort Emergency Communications System | Audit | ||
1 Ensure medical facilities monitor resilient high-frequency radio network training and staffing levels and maintain enough trained staff to operate the resilient high-frequency radio network.
Closure Date:
2 Ensure that the appropriate stakeholders know the program office responsible for the resilient high-frequency radio network and understand the roles and responsibilities for the Veterans Health Administration’s Resilient High-Frequency Radio Network program.
Closure Date:
3 Finalize the Veterans Health Administration High-Frequency Radio Operations Plan.
Closure Date:
4 If additional resilient high-frequency radio network equipment is purchased, work with the contracting officer to provide guidance to facility representatives to ensure they verify radios are fully functional before acceptance.
Closure Date:
5 Conduct a risk assessment and provide guidance for the placement of resilient high-frequency radio networks within facilities and any needed monitoring schedules.
Closure Date:
6 Ensure sites can obtain repairs for broken or inoperable resilient high-frequency radio network equipment.
Closure Date:
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| 22-01594-86 | Inadequate Coordination of Care for a Patient at the West Palm Beach VA Healthcare System in Florida | Hotline Healthcare Inspection | ||
1 The West Palm Beach VA Healthcare System Director ensures that pulmonary providers communicate and document test results and surveillance care plans to patients.
Closure Date:
2 The West Palm Beach VA Healthcare System Director ensures that pulmonary providers and staff are trained on the use of return-to-clinic orders and monitors for compliance.
Closure Date:
3 The West Palm Beach VA Healthcare System Director ensures that chiropractor providers review community care notes and takes action as needed.
Closure Date:
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| 21-03680-80 | Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, IN | Hotline Healthcare Inspection | ||
1 The Richard L. Roudebush VA Medical Center Director conducts a comprehensive review of the patient’s care received in the Emergency Department and primary care setting, consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel action is warranted, and takes action.
Closure Date:
2 The Richard L. Roudebush VA Medical Center Director evaluates the Emergency Department alcohol withdrawal treatment protocol and ensures policy aligns with evidence-based care guidelines.
Closure Date:
3 The Richard L. Roudebush VA Medical Center Director considers establishing written procedures for discharge planning in the Emergency Department, including documentation of contact with family members regarding notification of discharge and follow-up when applicable.
Closure Date:
4 The Richard L. Roudebush VA Medical Center Director expedites written guidance for primary care staff’s care coordination of patients discharged from the Emergency Department including documentation expectations and oversight responsibilities, and monitors compliance.
Closure Date:
5 The Richard L. Roudebush VA Medical Center Director conducts a full review of the patient’s care, determines if an institutional disclosure is warranted, and takes action as indicated.
Closure Date:
6 The Richard L Roudebush VA Medical Center Director establishes a protocol for the administrative staff management of potentially urgent patient care needs, ensures training, and monitors compliance.
Closure Date:
7 The Richard L. Roudebush VA Medical Center Director develops procedures for the management of intoxicated patients in the primary care setting to include documentation of safe transport considerations.
Closure Date:
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15039